Healthcare Provider Details

I. General information

NPI: 1831333509
Provider Name (Legal Business Name): LISA DOUTHERD LLPC, BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W WILLOW ST
LANSING MI
48906-4740
US

IV. Provider business mailing address

5031 PARK LAKE RD
EAST LANSING MI
48823-3835
US

V. Phone/Fax

Practice location:
  • Phone: 517-702-3500
  • Fax: 517-484-5169
Mailing address:
  • Phone: 517-332-0811
  • Fax: 517-332-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802074536
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401012198
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: