Healthcare Provider Details

I. General information

NPI: 1144058132
Provider Name (Legal Business Name): LISA ANNE RADLOFF BS, MCJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43740 N GROESBECK HWY
CLINTON TWP MI
48036-1139
US

IV. Provider business mailing address

4921 CROOKS RD APT M11
ROYAL OAK MI
48073-1265
US

V. Phone/Fax

Practice location:
  • Phone: 586-469-7629
  • Fax: 586-466-4143
Mailing address:
  • Phone: 586-265-0833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: