Healthcare Provider Details

I. General information

NPI: 1124376306
Provider Name (Legal Business Name): LISA D LARSON LMSW, ACSW, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 03/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 CENTER ST
CLIO MI
48420-1148
US

IV. Provider business mailing address

740 CENTER ST
CLIO MI
48420-1148
US

V. Phone/Fax

Practice location:
  • Phone: 810-686-7313
  • Fax: 810-686-7315
Mailing address:
  • Phone: 810-686-7313
  • Fax: 810-686-7315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801058069
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: