Healthcare Provider Details

I. General information

NPI: 1669610333
Provider Name (Legal Business Name): LISA J. FICKER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 SIX FORKS RD STE 207
RALEIGH NC
27615-3094
US

IV. Provider business mailing address

22561 DOVER HILL CT
FARMINGTON HILLS MI
48335-3912
US

V. Phone/Fax

Practice location:
  • Phone: 248-613-9669
  • Fax:
Mailing address:
  • Phone: 248-613-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015019
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: