Healthcare Provider Details

I. General information

NPI: 1619013521
Provider Name (Legal Business Name): LISA MARIE MARTIN MA, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E CHART ST
PLAINWELL MI
49080-1768
US

IV. Provider business mailing address

8433 N 12TH ST
KALAMAZOO MI
49009-9017
US

V. Phone/Fax

Practice location:
  • Phone: 269-685-6363
  • Fax: 269-685-5995
Mailing address:
  • Phone: 269-381-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6302007850
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301007850
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007850
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: