Provider Demographics
NPI:1376610154
Name:PHILLIPS, LISA MARIE (BS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19814 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1516
Mailing Address - Country:US
Mailing Address - Phone:313-543-7760
Mailing Address - Fax:
Practice Address - Street 1:2710 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1630
Practice Address - Country:US
Practice Address - Phone:248-543-1090
Practice Address - Fax:248-543-0017
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705289Medicaid