Healthcare Provider Details

I. General information

NPI: 1639550114
Provider Name (Legal Business Name): VIORICA TIPTIS LAZIN MS MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 13 MILE RD STE 100
MADISON HEIGHTS MI
48071-1873
US

IV. Provider business mailing address

711 W 13 MILE RD STE 100
MADISON HEIGHTS MI
48071-1873
US

V. Phone/Fax

Practice location:
  • Phone: 248-298-1000
  • Fax: 248-298-1006
Mailing address:
  • Phone: 248-298-1000
  • Fax: 248-298-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401014042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: