Provider Demographics
NPI:1053980326
Name:RAE, LISA M (MSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:RAE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 TORREY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3327
Mailing Address - Country:US
Mailing Address - Phone:810-494-7180
Mailing Address - Fax:810-215-1334
Practice Address - Street 1:1100 TORREY RD STE 100
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3327
Practice Address - Country:US
Practice Address - Phone:810-494-7180
Practice Address - Fax:248-692-4936
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI68011043201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical