Healthcare Provider Details

I. General information

NPI: 1720699077
Provider Name (Legal Business Name): LISA J BILDEAUX MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

IV. Provider business mailing address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

V. Phone/Fax

Practice location:
  • Phone: 651-677-4639
  • Fax: 651-677-4640
Mailing address:
  • Phone: 651-677-4639
  • Fax: 651-677-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2561
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2561
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: