Provider Demographics
NPI:1750646816
Name:MENUCK, LISA MICHELLE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:MENUCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20300 CIVIC CENTER DRIVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-559-8190
Mailing Address - Fax:248-559-8776
Practice Address - Street 1:200 DIVERSION ST.
Practice Address - Street 2:SUITE 10A
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-559-8190
Practice Address - Fax:248-559-8776
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6801070691104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker