Provider Demographics
NPI:1740371442
Name:IRWIN, LISA MICHELLE (PSY D)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:IRWIN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53298 HUNTERS CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2087
Mailing Address - Country:US
Mailing Address - Phone:586-677-0722
Mailing Address - Fax:
Practice Address - Street 1:52188 VAN DYKE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3567
Practice Address - Country:US
Practice Address - Phone:586-323-0176
Practice Address - Fax:586-254-7776
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008401103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E04587F7Medicare ID - Type UnspecifiedMEDICARE