MEDICARE: LISA SAKALA M.A., L.L.P

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	103TC0700X	Clinical Psychologist	6361003293	MI

General Provider Information

NPI Number	:	1952768327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SAKALA M.A., L.L.P

Provider Business Mailing Address
First Line	:	11130 CANYON CREEK DR
Second Line	:
City	:	ZEELAND
State	:	MI
Zip	:	49464-9120
Country	:	US
Telephone Number	:	810-348-9911
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 AXTELL DR STE 100
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4400
Country	:	US
Telephone Number	:	248-613-5377
Fax Number	:

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

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	08/12/2020

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