Provider Demographics
NPI:1275131989
Name:REISSMANN, LYDIA BELLE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:BELLE
Last Name:REISSMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1017
Mailing Address - Country:US
Mailing Address - Phone:715-297-9807
Mailing Address - Fax:
Practice Address - Street 1:12553 W EXPLORER DR STE 190
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1612
Practice Address - Country:US
Practice Address - Phone:208-972-5254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNAMedicaid