Provider Demographics
NPI:1376942599
Name:WEISS, LISA ANN (CP,MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WEISS
Suffix:
Gender:F
Credentials:CP,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 TOWER HILL LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3061
Mailing Address - Country:US
Mailing Address - Phone:586-446-9807
Mailing Address - Fax:248-569-9410
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 207
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-712-1129
Practice Address - Fax:248-569-9410
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2050103TB0200X
MI63010069762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI7767003Medicare PIN