Healthcare Provider Details

I. General information

NPI: 1124738182
Provider Name (Legal Business Name): MARISSA LEEANN HAVARD LMSW- CLINICAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LAKE LANSING RD STE 120
LANSING MI
48912-3798
US

IV. Provider business mailing address

1701 LAKE LANSING RD STE 120
LANSING MI
48912-3798
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 989-413-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6901114325
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114325
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: