Basic Information
| Provider Information | |||||||||
| NPI: | 1104926880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MSW ACSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4084 OKEMOS RD STE A | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474848 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4084 OKEMOS RD STE A | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2006 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801064670 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.