Provider Demographics
NPI:1801175799
Name:BACH, LISA HAAS (MA LLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:HAAS
Last Name:BACH
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 1:715 BAUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2070
Mailing Address - Country:US
Mailing Address - Phone:248-346-3845
Mailing Address - Fax:
Practice Address - Street 1:725 S ADAMS RD
Practice Address - Street 2:SUITE 254
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6902
Practice Address - Country:US
Practice Address - Phone:248-346-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006457103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist