MEDICARE: LISE A SHIRTZ PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301011642	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	450002000	OTHER		POLICY #

General Provider Information

NPI Number	:	1649338534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISE A SHIRTZ PH.D.

Provider Business Mailing Address
First Line	:	36975 UTICA RD
Second Line	:	SUITE 103
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48036-1685
Country	:	US
Telephone Number	:	586-226-3440
Fax Number	:	586-226-3672

Provider Business Practice Location Address
First Line	:	36975 UTICA RD
Second Line	:	SUITE 103
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48036-1685
Country	:	US
Telephone Number	:	586-226-3440
Fax Number	:	586-226-3740

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	11/17/2011

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