Healthcare Provider Details

I. General information

NPI: 1205759107
Provider Name (Legal Business Name): SAMUEL FISHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E TERRY ST, BLDG 63, 7TH FLOOR
POCATELLO ID
83201
US

IV. Provider business mailing address

1827 S FAIRWAY DR
POCATELLO ID
83201-2330
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-3156
  • Fax:
Mailing address:
  • Phone: 208-403-2463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: