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General NPI Number Information
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NPI Number | 1437885811
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Entity Type | Individual
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Provider Name | LISA KHOURY M.A., ED.S
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Gender | Female
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Dates
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Enumeration Date | 07/27/2022
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Last Update Date | 07/27/2022
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Provider Practice Location Address
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Address Line | 19900 E 10 MILE RD STE 102
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48080-4412
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Country | US
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Telephone | 586-776-3366
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Fax |
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Provider Business Mailing Address
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Address Line | 840 BISHOP RD
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City | GROSSE POINTE PARK
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State | MI
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Zip | 48230-1924
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Country | US
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Telephone | 313-220-0009
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6361002269
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License Number State | MI
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