Provider Demographics
NPI:1710410220
Name:GOLD, LISA (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:SHAPIRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3290 SHADYDALE LN
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1855
Mailing Address - Country:US
Mailing Address - Phone:248-343-5779
Mailing Address - Fax:
Practice Address - Street 1:30150 TELEGRAPH RD STE 245
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:248-343-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150101323104100000X
MI68010981401041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical