Provider Demographics
NPI:1982460895
Name:LUSK, LIISA (LLC)
Entity Type:Individual
Prefix:
First Name:LIISA
Middle Name:
Last Name:LUSK
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 PAULINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5567
Mailing Address - Country:US
Mailing Address - Phone:415-205-1410
Mailing Address - Fax:
Practice Address - Street 1:2002 HOGBACK RD STE 18
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9736
Practice Address - Country:US
Practice Address - Phone:734-956-0051
Practice Address - Fax:888-976-6019
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022872101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional