Healthcare Provider Details

I. General information

NPI: 1649661869
Provider Name (Legal Business Name): MRS. ELISHA LIETO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MONROE STREET
MONROE MI
48161-1440
US

IV. Provider business mailing address

621 MONROE STREET
MONROE MI
48161-1440
US

V. Phone/Fax

Practice location:
  • Phone: 734-265-0334
  • Fax: 734-384-3030
Mailing address:
  • Phone: 734-265-0334
  • Fax: 734-384-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: