Provider Demographics
NPI:1619013521
Name:MARTIN, LISA MARIE (MA, LLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8433 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9017
Mailing Address - Country:US
Mailing Address - Phone:269-381-6351
Mailing Address - Fax:
Practice Address - Street 1:112 E CHART ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1768
Practice Address - Country:US
Practice Address - Phone:269-685-6363
Practice Address - Fax:269-685-5995
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6302007850103TC1900X
MI6301007850101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health