Basic Information
| Provider Information | |||||||||
| NPI: | 1639590813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAMANCUSA | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 PLAINFIELD AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162793869 | ||||||||
| FaxNumber: | 6166084657 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 PLAINFIELD AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162793869 | ||||||||
| FaxNumber: | 6166084657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2013 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301012462 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.