Provider Demographics
NPI:1669599684
Name:ISH, LYNETTE MARIE (MS, FAODP)
Entity type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:MARIE
Last Name:ISH
Suffix:
Gender:F
Credentials:MS, FAODP
Other - Prefix:MRS
Other - First Name:LYNETTE
Other - Middle Name:MARIE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, FAODP
Mailing Address - Street 1:18339 BLUE HERON DR E
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-9245
Mailing Address - Country:US
Mailing Address - Phone:248-773-1963
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:SUITE 1000 SOUTH
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-347-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)