MEDICARE: LISA MARIE WALES LLPC

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	101YM0800X	Mental Health Counselor	6401018643	MI

General Provider Information

NPI Number	:	1750966826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE WALES LLPC

Provider Business Mailing Address
First Line	:	2739 ARROWWOOD LN
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-3713
Country	:	US
Telephone Number	:	269-744-1160
Fax Number	:

Provider Business Practice Location Address
First Line	:	3054 S 9TH ST STE B
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49009-6250
Country	:	US
Telephone Number	:	269-743-6139
Fax Number	:

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

Provider Enumeration Date	:	03/10/2021
Last Update Date	:	03/10/2021

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