Provider Demographics
NPI:1942822721
Name:FOX, LISA MARIE (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:FOX
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1150 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5447
Mailing Address - Country:US
Mailing Address - Phone:616-485-2931
Mailing Address - Fax:
Practice Address - Street 1:12265 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8613
Practice Address - Country:US
Practice Address - Phone:616-392-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801106895101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health