Provider Demographics
NPI:1356808570
Name:LIZCANO, MARIA DEL CARMEN
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:DEL CARMEN
Last Name:LIZCANO
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 1:9775 RAVENSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3287
Mailing Address - Country:US
Mailing Address - Phone:517-918-6392
Mailing Address - Fax:
Practice Address - Street 1:9775 RAVENSHIRE DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3287
Practice Address - Country:US
Practice Address - Phone:517-918-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIN541048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty