Healthcare Provider Details

I. General information

NPI: 1346287349
Provider Name (Legal Business Name): LISA ROBIN ELROM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UPC LIVONIA 16836 NEWBURGH RD
LIVONIA MI
48154
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 888-362-7792
  • Fax:
Mailing address:
  • Phone: 248-581-5971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301005907
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: