Basic Information
| Provider Information | |||||||||
| NPI: | 1124516000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA LAMANCUSA MA, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4829 E BELTLINE AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163643301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4829 E BELTLINE AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163643301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | LAMANCUSA | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6163643301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LIMITED LICENSED PSY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 6301012462 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.