Healthcare Provider Details

I. General information

NPI: 1023003340
Provider Name (Legal Business Name): LISA KIMBERLY LARGO-MARSH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 08/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8799 GULL ROAD SUITE 1
RICHLAND MI
49083
US

IV. Provider business mailing address

8799 GULL RD SUITE 1
RICHLAND MI
49083-9100
US

V. Phone/Fax

Practice location:
  • Phone: 269-629-2207
  • Fax: 269-731-2324
Mailing address:
  • Phone: 269-629-2207
  • Fax: 269-629-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301008181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: