Basic Information
Provider Information | |||||||||
NPI: | 1104255637 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANTISTE-FISHER | ||||||||
FirstName: | DACIA | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANTISTE | ||||||||
OtherFirstName: | DACIA | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LAC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 880 | ||||||||
Address2: |   | ||||||||
City: | ST. IGNATIUS | ||||||||
State: | MT | ||||||||
PostalCode: | 59865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067453525 | ||||||||
FaxNumber: | 4067453529 | ||||||||
Practice Location | |||||||||
Address1: | #5 4TH AVE. E. | ||||||||
Address2: |   | ||||||||
City: | POLSON | ||||||||
State: | MT | ||||||||
PostalCode: | 59860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067453525 | ||||||||
FaxNumber: | 4067453529 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2013 | ||||||||
LastUpdateDate: | 06/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LAC-LAC-LIC-1930 | MT | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 1930 | MT | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 30076 | MT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.