Provider Demographics
NPI:1619486610
Name:DAVIS, LISA MARIE (LLPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DAVIS
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 1:101 N SHORE DR APT 17
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1170
Mailing Address - Country:US
Mailing Address - Phone:512-202-7764
Mailing Address - Fax:
Practice Address - Street 1:1030 MINERS RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9625
Practice Address - Country:US
Practice Address - Phone:269-408-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016265101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional