Provider Demographics
NPI:1538310016
Name:GILES, LISA MARIAN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIAN
Last Name:GILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 GOLDENEYE CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6077
Mailing Address - Country:US
Mailing Address - Phone:616-552-3571
Mailing Address - Fax:
Practice Address - Street 1:36 W 8TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2701
Practice Address - Country:US
Practice Address - Phone:616-294-8570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006553106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist