Provider Demographics
NPI:1467675504
Name:SHAFFER, LISA ANN (LBSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21946 CARLYSLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3634
Mailing Address - Country:US
Mailing Address - Phone:313-730-0969
Mailing Address - Fax:
Practice Address - Street 1:7309 BRYN ATHYN WAY APT 232
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6234
Practice Address - Country:US
Practice Address - Phone:313-282-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6802072909104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker