Healthcare Provider Details

I. General information

NPI: 1265066260
Provider Name (Legal Business Name): LISA MARIE ZWAGERMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 N 122ND ST
WAUWATOSA WI
53226-3122
US

IV. Provider business mailing address

1434 N 122ND ST
WAUWATOSA WI
53226-3122
US

V. Phone/Fax

Practice location:
  • Phone: 616-890-2091
  • Fax:
Mailing address:
  • Phone: 616-890-2091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6672-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: