Healthcare Provider Details

I. General information

NPI: 1629437918
Provider Name (Legal Business Name): LISA YOUNGMAN-LOOSE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HAMMOND RD E
TRAVERSE CITY MI
49686-8641
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 231-947-2255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017908
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: