Provider Demographics
NPI:1104926880
Name:WHITEHEAD, LISA B (MSW ACSW LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:MSW ACSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4084 OKEMOS RD STE A
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3258
Mailing Address - Country:US
Mailing Address - Phone:517-347-4848
Mailing Address - Fax:
Practice Address - Street 1:4084 OKEMOS RD STE A
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3258
Practice Address - Country:US
Practice Address - Phone:517-347-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801064670104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
M76100001Medicare PIN