Provider Demographics
NPI:1649338534
Name:SHIRTZ, LISE A (PHD)
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:A
Last Name:SHIRTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36975 UTICA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1685
Mailing Address - Country:US
Mailing Address - Phone:586-226-3440
Mailing Address - Fax:586-226-3672
Practice Address - Street 1:36975 UTICA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1685
Practice Address - Country:US
Practice Address - Phone:586-226-3440
Practice Address - Fax:586-226-3740
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
450002000OtherPOLICY #