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NPI Code Detail

MEDICARE: LISA J BILDEAUX MA, LPCC

MEDICARE: LISA J BILDEAUX MA, LPCC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor2561MN
2101YP2500XProfessional Counselor2561MN

General Provider Information

NPI Number : 1720699077
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA J BILDEAUX MA, LPCC
Provider Business Mailing Address
First Line : 2222 W GRAND RIVER AVE STE A
Second Line :
City : OKEMOS
State : MI
Zip : 48864-1604
Country : US
Telephone Number : 651-677-4639
Fax Number : 651-677-4640
Provider Business Practice Location Address
First Line : 2222 W GRAND RIVER AVE STE A
Second Line :
City : OKEMOS
State : MI
Zip : 48864-1604
Country : US
Telephone Number : 651-677-4639
Fax Number : 651-677-4640
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/11/2020
Last Update Date : 05/27/2026

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