=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215725320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP G. LIRA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2025
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 LOUISA ST STE 205
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-556-4359
-----------------------------------------------------
Fax | 313-583-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 LOUISA ST STE 205
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-497-2665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------