Healthcare Provider Details

I. General information

NPI: 1306799655
Provider Name (Legal Business Name): LISA MECHAM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
APO AA
98431
US

IV. Provider business mailing address

930 W CENTER ST
POCATELLO ID
83204-4249
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61604705
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: