Healthcare Provider Details

I. General information

NPI: 1073939583
Provider Name (Legal Business Name): LISA TAMBLYN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE STE C
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

5242 PLAINFIELD AVE NE STE C
GRAND RAPIDS MI
49525-1084
US

V. Phone/Fax

Practice location:
  • Phone: 616-318-6394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401013914
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: