Provider Demographics
NPI:1518231901
Name:MATHIS, LISA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MATHIS
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 1:376 E APPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3466
Mailing Address - Country:US
Mailing Address - Phone:231-724-3699
Mailing Address - Fax:231-724-4188
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:231-724-3699
Practice Address - Fax:231-724-4188
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010929721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical