Provider Demographics
NPI:1083274294
Name:ISOM, ALLY REID
Entity Type:Individual
Prefix:
First Name:ALLY
Middle Name:REID
Last Name:ISOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 BECKER AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1335
Mailing Address - Country:US
Mailing Address - Phone:313-407-4561
Mailing Address - Fax:
Practice Address - Street 1:2935 BIRCH HOLLOW DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2301
Practice Address - Country:US
Practice Address - Phone:734-971-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician