Provider Demographics
NPI:1912358458
Name:REEDY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:REEDY
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 1:444 CHESTER ST
Mailing Address - Street 2:#402
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1471
Mailing Address - Country:US
Mailing Address - Phone:248-762-0257
Mailing Address - Fax:
Practice Address - Street 1:17421 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3165
Practice Address - Country:US
Practice Address - Phone:313-255-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010997291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical