Provider Demographics
NPI:1265143465
Name:LILES-MOULTRIE, MYSHIA VENISE (LLPC)
Entity type:Individual
Prefix:
First Name:MYSHIA
Middle Name:VENISE
Last Name:LILES-MOULTRIE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4642 S HAGADORN RD APT E19
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5326
Mailing Address - Country:US
Mailing Address - Phone:989-522-2580
Mailing Address - Fax:
Practice Address - Street 1:5030 NORTHWIND DR STE 101
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5034
Practice Address - Country:US
Practice Address - Phone:517-333-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451021996101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health