Provider Demographics
NPI:1043352701
Name:PETER M LISIECKI PHD PC INC
Entity type:Organization
Organization Name:PETER M LISIECKI PHD PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LISIECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-227-1999
Mailing Address - Street 1:7960 GRAND RIVER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7960 W. GRAND RIVER
Practice Address - Street 2:STE 120
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7335
Practice Address - Country:US
Practice Address - Phone:810-227-1999
Practice Address - Fax:810-225-2265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003173103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D745030OtherBCBSM PIN
MI045199OtherVALUE OPTIONS PIN
MI0D74503Medicare ID - Type Unspecified