Healthcare Provider Details

I. General information

NPI: 1104146349
Provider Name (Legal Business Name): LISA D TENNER MA, LPC, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 E LANSING DR
EAST LANSING MI
48823-7755
US

IV. Provider business mailing address

2775 E LANSING DR
EAST LANSING MI
48823-7755
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-1616
  • Fax: 517-336-4797
Mailing address:
  • Phone: 517-332-1616
  • Fax: 517-336-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1132759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: