Healthcare Provider Details

I. General information

NPI: 1275155657
Provider Name (Legal Business Name): MADISON LISH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W CANFIELD AVE STE 300
COEUR D ALENE ID
83815-7953
US

IV. Provider business mailing address

560 W CANFIELD AVE STE 300
COEUR D ALENE ID
83815-7953
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-7111
  • Fax:
Mailing address:
  • Phone: 208-758-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4071375
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: