Provider Demographics
NPI:1104255637
Name:ANTISTE-FISHER, DACIA LEE (LCSW)
Entity type:Individual
Prefix:
First Name:DACIA
Middle Name:LEE
Last Name:ANTISTE-FISHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DACIA
Other - Middle Name:LEE
Other - Last Name:ANTISTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:P.O. BOX 880
Mailing Address - Street 2:
Mailing Address - City:ST. IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-3529
Practice Address - Street 1:5 4TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2117
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:406-745-3529
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-300761041C0700X
MT1930101YA0400X
MTLAC-LAC-LIC-1930101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)