Healthcare Provider Details

I. General information

NPI: 1114652328
Provider Name (Legal Business Name): MRS. LISA MARIE ESPARZA-SADIKOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E MAIN ST
NORTHVILLE MI
48167-7400
US

IV. Provider business mailing address

324 E MAIN ST
NORTHVILLE MI
48167-7400
US

V. Phone/Fax

Practice location:
  • Phone: 734-306-7702
  • Fax:
Mailing address:
  • Phone: 734-306-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401020209
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: