Provider Demographics
NPI:1477979987
Name:CIACIUCH, LISA JO (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JO
Last Name:CIACIUCH
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 1:315 W LARKIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5152
Mailing Address - Country:US
Mailing Address - Phone:989-835-7511
Mailing Address - Fax:
Practice Address - Street 1:1714 EASTMAN AVENUE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-631-5390
Practice Address - Fax:989-631-0488
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010957221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical