Healthcare Provider Details

I. General information

NPI: 1144797341
Provider Name (Legal Business Name): LISA MARIE STOLL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6548 TOWN CENTER DR STE D
CLARKSTON MI
48346-4823
US

IV. Provider business mailing address

180 PINE TREE RIDGE DR UNIT 3
WATERFORD MI
48327-4323
US

V. Phone/Fax

Practice location:
  • Phone: 800-693-1916
  • Fax:
Mailing address:
  • Phone: 248-431-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: