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: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S WOODRUFF AVE STE 101
IDAHO FALLS ID
83401-5286
US

IV. Provider business mailing address

725 S WOODRUFF AVE STE 101
IDAHO FALLS ID
83401-5286
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY202807
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: