Basic Information
| Provider Information | |||||||||
| NPI: | 1134647639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIVOSKY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5514 MAPLE PARK DR | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485073915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104711890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 09/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801100487 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1043554348 | 05 | MI | MEDICAID |