Provider Demographics
NPI:1750966826
Name:WALES, LISA MARIE (LLPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WALES
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 ARROWWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3713
Mailing Address - Country:US
Mailing Address - Phone:269-744-1160
Mailing Address - Fax:
Practice Address - Street 1:3054 S 9TH ST STE B
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6250
Practice Address - Country:US
Practice Address - Phone:269-743-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health