Basic Information
| Provider Information | |||||||||
| NPI: | 1548542186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISZAK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6585 LUANA AVE | ||||||||
| Address2: | |||||||||
| City: | ALLEN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481012404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739913661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30150 TELEGRAPH RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2011 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071008523 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6301014853 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.