Healthcare Provider Details

I. General information

NPI: 1922983733
Provider Name (Legal Business Name): LISA M PETERSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENMOOR AVE SE STE 215
GRAND RAPIDS MI
49546-2395
US

IV. Provider business mailing address

1233 HERRICK AVE NE
GRAND RAPIDS MI
49505-5536
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax:
Mailing address:
  • Phone: 989-385-1628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801117137
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: