Basic Information
| Provider Information | |||||||||
| NPI: | 1518272368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAROUN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39555 W 10 MILE RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484267200 | ||||||||
| FaxNumber: | 2484267335 | ||||||||
| Practice Location | |||||||||
| Address1: | 39555 W 10 MILE RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484267200 | ||||||||
| FaxNumber: | 2484267335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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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 | 133V00000X | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 954207 | 01 | MI | CDR | OTHER |