Provider Demographics
NPI:1982999074
Name:KISHIYAMA, LISA LA'REE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LA'REE
Last Name:KISHIYAMA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 SAINT CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7330
Mailing Address - Country:US
Mailing Address - Phone:208-681-4808
Mailing Address - Fax:
Practice Address - Street 1:660 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5299
Practice Address - Country:US
Practice Address - Phone:208-523-1558
Practice Address - Fax:208-529-4788
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-31426101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional