MEDICARE: LAWRENCE FISCHETTI PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301006461	MI
2	103T00000X	Psychologist	6301006461	MI

General Provider Information

NPI Number	:	1477510774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE FISCHETTI PHD

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD STE 3D
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18501 ROTUNDA DR STE 100
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3891
Country	:	US
Telephone Number	:	313-996-1930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	12/28/2023

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