Provider Demographics
NPI:1477588697
Name:VEENSTRA, LISA LOWTHER (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LOWTHER
Last Name:VEENSTRA
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 1:22720 MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2021
Mailing Address - Country:US
Mailing Address - Phone:313-274-3700
Mailing Address - Fax:313-274-3767
Practice Address - Street 1:22720 MICHIGAN AVE STE 175
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2000
Practice Address - Country:US
Practice Address - Phone:313-274-3700
Practice Address - Fax:313-274-3767
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010799551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588855100OtherMEDICARE NPI