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: N

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S POKEGAMA AVE
GRAND RAPIDS MN
55744-3800
US

IV. Provider business mailing address

12299 S ELLIS AVE UNIT 106
TRAVERSE CITY MI
49684-2712
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-2001
  • Fax:
Mailing address:
  • Phone: 218-327-2001
  • Fax:

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: