Provider Demographics
NPI:1043412240
Name:MCILVENNA, LISA MARIE (DMIN)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:MCILVENNA
Suffix:
Gender:F
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 HOUGHTEN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2942
Mailing Address - Country:US
Mailing Address - Phone:248-879-3220
Mailing Address - Fax:
Practice Address - Street 1:315 W LARKIN ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-835-7511
Practice Address - Fax:898-357-5112
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional