Healthcare Provider Details

I. General information

NPI: 1629008420
Provider Name (Legal Business Name): LISA A MEDOFF PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MADISON ST
GROSSE POINTE FARMS MI
48236-3209
US

IV. Provider business mailing address

440 MADISON ST
GROSSE POINTE FARMS MI
48236-3209
US

V. Phone/Fax

Practice location:
  • Phone: 248-854-9573
  • Fax:
Mailing address:
  • Phone: 248-854-9573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number63010007759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: