Healthcare Provider Details

I. General information

NPI: 1316175862
Provider Name (Legal Business Name): ROBERT D. LISOTA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 LEONIDAS ST
CHUBBUCK ID
83202-1664
US

IV. Provider business mailing address

774 LEONIDAS ST
CHUBBUCK ID
83202-1664
US

V. Phone/Fax

Practice location:
  • Phone: 208-220-1944
  • Fax: 208-516-1569
Mailing address:
  • Phone: 208-220-1944
  • Fax: 208-516-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY202807
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: