Provider Demographics
NPI:1306320064
Name:LISA LASALA, PHD, PC
Entity type:Organization
Organization Name:LISA LASALA, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMSW
Authorized Official - Phone:248-207-1863
Mailing Address - Street 1:999 HAYNES ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6775
Mailing Address - Country:US
Mailing Address - Phone:248-207-1863
Mailing Address - Fax:
Practice Address - Street 1:999 HAYNES ST STE 300
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6775
Practice Address - Country:US
Practice Address - Phone:248-207-1863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty