MEDICARE: LISA A CHARLES M.S.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PPS-0601360	VA
2	101Y00000X	Counselor	6451023963	MI
3	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1346482577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A CHARLES M.S.ED.

Provider Business Mailing Address
First Line	:	41521 W 11 MILE RD
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48375-1803
Country	:	US
Telephone Number	:	804-447-8049
Fax Number	:	804-447-8049

Provider Business Practice Location Address
First Line	:	1751 RIVER BEND DR
Second Line	:
City	:	ALLEGAN
State	:	MI
Zip	:	49010-8227
Country	:	US
Telephone Number	:	269-512-5178
Fax Number	:	269-645-5930

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2009
Last Update Date	:	03/02/2026

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