Healthcare Provider Details

I. General information

NPI: 1982999074
Provider Name (Legal Business Name): LISA LA'REE KISHIYAMA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S WOODRUFF AVE
IDAHO FALLS ID
83401-5299
US

IV. Provider business mailing address

2820 SAINT CHARLES AVE
IDAHO FALLS ID
83404-7330
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1558
  • Fax: 208-529-4788
Mailing address:
  • Phone: 208-681-4808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLMSW-31426
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: