Provider Demographics
NPI:1356511703
Name:LARSON, LISA RAYMOND (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RAYMOND
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2126
Mailing Address - Country:US
Mailing Address - Phone:734-635-9365
Mailing Address - Fax:
Practice Address - Street 1:321 S MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2126
Practice Address - Country:US
Practice Address - Phone:734-635-9365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-01
Last Update Date:2008-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010469601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical