Provider Demographics
NPI:1063659084
Name:RISS, ELIZABETH BIRCHMORE (LCPC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BIRCHMORE
Last Name:RISS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:BIRCHMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:1819 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3952
Mailing Address - Country:US
Mailing Address - Phone:208-220-2162
Mailing Address - Fax:208-895-8049
Practice Address - Street 1:403 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1610
Practice Address - Country:US
Practice Address - Phone:208-220-2162
Practice Address - Fax:208-895-8049
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433089899Medicaid