Provider Demographics
NPI:1750654109
Name:MITTON, LISA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:MITTON
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 1:414 SHOUP AVE W STE B
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5042
Mailing Address - Country:US
Mailing Address - Phone:208-814-9100
Mailing Address - Fax:208-814-9903
Practice Address - Street 1:414 SHOUP AVE W STE B
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5042
Practice Address - Country:US
Practice Address - Phone:208-814-9100
Practice Address - Fax:208-814-9903
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical