Provider Demographics
NPI:1740306695
Name:FISHER-SZELES, TRINA CHRISTEEN (LCSW)
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:CHRISTEEN
Last Name:FISHER-SZELES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:TRINA
Other - Middle Name:CHRISTEEN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1121 E STATE ST
Mailing Address - Street 2:STE 107
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6062
Mailing Address - Country:US
Mailing Address - Phone:208-850-7958
Mailing Address - Fax:208-441-9947
Practice Address - Street 1:1121 E STATE ST
Practice Address - Street 2:STE 107
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6062
Practice Address - Country:US
Practice Address - Phone:208-850-7958
Practice Address - Fax:208-441-9947
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-253461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806014000Medicaid
ID806014000Medicaid