Provider Demographics
NPI:1225411911
Name:MCGOWAN, LYSHAY
Entity Type:Individual
Prefix:
First Name:LYSHAY
Middle Name:
Last Name:MCGOWAN
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 1:19441 SORRENTO ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1235
Mailing Address - Country:US
Mailing Address - Phone:313-622-7469
Mailing Address - Fax:
Practice Address - Street 1:1852 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1006
Practice Address - Country:US
Practice Address - Phone:313-894-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)