Provider Demographics
NPI:1457121667
Name:LAVAN, LISA (LLMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAVAN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1106
Mailing Address - Country:US
Mailing Address - Phone:734-929-7455
Mailing Address - Fax:
Practice Address - Street 1:5340 PLYMOUTH RD STE 110
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9558
Practice Address - Country:US
Practice Address - Phone:734-929-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851117565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health