Provider Demographics
NPI:1477900819
Name:BOOMERS, LISA MARIE (LLPC)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIE
Last Name:BOOMERS
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W MAIN ST LOT 56
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1547
Mailing Address - Country:US
Mailing Address - Phone:616-901-0401
Mailing Address - Fax:
Practice Address - Street 1:1215 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3849
Practice Address - Country:US
Practice Address - Phone:616-742-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017408101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)