Provider Demographics
NPI:1992298798
Name:QUAGLIA, LISA (LLMSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:QUAGLIA
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:QUAGLIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1255 N OAKLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-599-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801107702104100000X, 1041C0700X
MI68011015071041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIXYH916237730OtherBCBS