Provider Demographics
NPI:1023003340
Name:LARGO-MARSH, LISA KIMBERLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KIMBERLY
Last Name:LARGO-MARSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8799 GULL RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9100
Mailing Address - Country:US
Mailing Address - Phone:269-629-2207
Mailing Address - Fax:269-629-2207
Practice Address - Street 1:8799 GULL ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083
Practice Address - Country:US
Practice Address - Phone:269-629-2207
Practice Address - Fax:269-731-2324
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114812OtherVALUE OPTIONS
MI1148122OtherVALUE OPTIONS
MI680C960810OtherBCBS OF MICHIGAN
MI21170586108OtherBEECH STREET CORPORATION
MI21170586108OtherBEECH STREET CORPORATION