Provider Demographics
NPI:1912367715
Name:HARRISON, KEISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:HARRISON
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6302
Practice Address - Country:US
Practice Address - Phone:208-994-1934
Practice Address - Fax:208-706-7059
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31456104100000X
IDLCSW-363721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker