Provider Demographics
NPI:1821759119
Name:LISH, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E 2ND AVE # 104
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7888
Mailing Address - Country:US
Mailing Address - Phone:208-241-9715
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY STE D
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-618-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician