Provider Demographics
NPI:1093863680
Name:LANZISERA, PHILIP J (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:LANZISERA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:ONE FORD PLACE 1F -BEHAVIORAL
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-876-6677
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:ONE FORD PLACE 1F -BEHAVIORAL
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-876-6677
Practice Address - Fax:313-874-6650
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001788103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPHD888810Medicaid
PL001788OtherCOMMERCIAL-COMMERCIAL NUMBER
PL001788OtherCHAMPUS-CHAMPUS
700H262290OtherBLUE CROSS-BLUE CROSS