Healthcare Provider Details

I. General information

NPI: 1659519411
Provider Name (Legal Business Name): LISA MARIE HOLMES L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 616-336-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801086382
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801086382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: