Provider Demographics
NPI:1164744983
Name:LISIECKI, PETER MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:LISIECKI
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 1:7960 GRAND RIVER RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7330
Mailing Address - Country:US
Mailing Address - Phone:810-227-1999
Mailing Address - Fax:810-225-2265
Practice Address - Street 1:7960 GRAND RIVER RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7330
Practice Address - Country:US
Practice Address - Phone:810-227-1999
Practice Address - Fax:810-225-2265
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D71307Medicare PIN