Healthcare Provider Details

I. General information

NPI: 1194004382
Provider Name (Legal Business Name): LISA KLEIN LISA KLEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA KLEIN LISA KLEIN, MA LLPC

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 N 10TH ST SUITE 110
KALAMAZOO MI
49009-5733
US

IV. Provider business mailing address

1090 N 10TH ST SUITE 110
KALAMAZOO MI
49009-5733
US

V. Phone/Fax

Practice location:
  • Phone: 269-375-4363
  • Fax: 269-375-4362
Mailing address:
  • Phone: 269-375-4363
  • Fax: 269-375-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberL1997720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: