Provider Demographics
NPI:1689940389
Name:CHIVINGTON, LIESEL S (LPC)
Entity Type:Individual
Prefix:
First Name:LIESEL
Middle Name:S
Last Name:CHIVINGTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 HUBERT RD
Mailing Address - Street 2:APT 1
Mailing Address - City:HUBBARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49747-9752
Mailing Address - Country:US
Mailing Address - Phone:989-727-3834
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3336
Practice Address - Fax:517-796-4561
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional