Healthcare Provider Details

I. General information

NPI: 1346482577
Provider Name (Legal Business Name): LISA A CHARLES M.S.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 RIVER BEND DR
ALLEGAN MI
49010-8227
US

IV. Provider business mailing address

41521 W 11 MILE RD
NOVI MI
48375-1803
US

V. Phone/Fax

Practice location:
  • Phone: 269-512-5178
  • Fax: 269-645-5930
Mailing address:
  • Phone: 804-447-8049
  • Fax: 804-447-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451023963
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPPS-0601360
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: