Healthcare Provider Details

I. General information

NPI: 1376942599
Provider Name (Legal Business Name): LISA ANN WEISS CP,MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30200 TELEGRAPH RD SUITE 207
BINGHAM FARMS MI
48025-4502
US

IV. Provider business mailing address

2511 TOWER HILL LN
ROCHESTER HILLS MI
48306-3061
US

V. Phone/Fax

Practice location:
  • Phone: 248-712-1129
  • Fax: 248-569-9410
Mailing address:
  • Phone: 586-446-9807
  • Fax: 248-569-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2050
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number63010069762
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: