Provider Demographics
NPI:1518272368
Name:MAROUN, LISA (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MAROUN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39555 W 10 MILE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2950
Mailing Address - Country:US
Mailing Address - Phone:248-426-7200
Mailing Address - Fax:248-426-7335
Practice Address - Street 1:39555 W 10 MILE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2950
Practice Address - Country:US
Practice Address - Phone:248-426-7200
Practice Address - Fax:248-426-7335
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI954207OtherCDR