Provider Demographics
NPI:1184947889
Name:WITULSKI, LISA S (MA LLP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:S
Last Name:WITULSKI
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2334
Mailing Address - Country:US
Mailing Address - Phone:313-224-3796
Mailing Address - Fax:
Practice Address - Street 1:570 CLINTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2334
Practice Address - Country:US
Practice Address - Phone:313-224-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical