Healthcare Provider Details

I. General information

NPI: 1821759119
Provider Name (Legal Business Name): ANDREW LISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 N MEADOWLARK WAY STE D
COEUR D ALENE ID
83815-5041
US

IV. Provider business mailing address

705 E 2ND AVE # 104
POST FALLS ID
83854-7888
US

V. Phone/Fax

Practice location:
  • Phone: 208-618-2593
  • Fax:
Mailing address:
  • Phone: 208-241-9715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number1-25-81998
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: