Healthcare Provider Details

I. General information

NPI: 1104732155
Provider Name (Legal Business Name): LOST LAKE HEALING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13419 SWISTIER DR
REMUS MI
49340-9381
US

IV. Provider business mailing address

13419 SWISTIER DR
REMUS MI
49340-9381
US

V. Phone/Fax

Practice location:
  • Phone: 231-408-7866
  • Fax:
Mailing address:
  • Phone: 231-408-7866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MCKENNA JO NIVISON
Title or Position: OWNER/OUTPATIENT THERAPIST
Credential: LMSW
Phone: 231-408-7866