Provider Demographics
NPI:1326711201
Name:KRIKKE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KRIKKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 VELTE RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48897-9734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:92 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881-5102
Practice Address - Country:US
Practice Address - Phone:616-642-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010654981041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool