Provider Demographics
NPI:1629698170
Name:BISHOP, MEKAYLA (LMSW)
Entity Type:Individual
Prefix:
First Name:MEKAYLA
Middle Name:
Last Name:BISHOP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MEKAYLA
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4789
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4789
Mailing Address - Country:US
Mailing Address - Phone:208-244-6437
Mailing Address - Fax:208-269-1226
Practice Address - Street 1:1223 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SUGAR CITY
Practice Address - State:ID
Practice Address - Zip Code:83448-5072
Practice Address - Country:US
Practice Address - Phone:208-359-0519
Practice Address - Fax:208-359-2493
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38878104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker