Provider Demographics
NPI:1427357326
Name:LISH, CRYSTAL ANGEL (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANGEL
Last Name:LISH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 CANYON RD S
Mailing Address - Street 2:
Mailing Address - City:MELBA
Mailing Address - State:ID
Mailing Address - Zip Code:83641-5271
Mailing Address - Country:US
Mailing Address - Phone:208-484-1374
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30593101YM0800X
IDLCSW-33082101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID850370802Medicaid
ID850370802Medicaid