Provider Demographics
NPI:1730636523
Name:LISA RAYMOND LARSON
Entity Type:Organization
Organization Name:LISA RAYMOND LARSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED SOCIAL WORKER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-635-9365
Mailing Address - Street 1:120 E LIBERTY ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2156
Mailing Address - Country:US
Mailing Address - Phone:734-635-9365
Mailing Address - Fax:734-661-4112
Practice Address - Street 1:120 E LIBERTY ST
Practice Address - Street 2:SUITE 320
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2156
Practice Address - Country:US
Practice Address - Phone:734-635-9365
Practice Address - Fax:734-661-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010469601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty