Provider Demographics
NPI:1548542186
Name:ISZAK, MARK GREGORY (PSYD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:ISZAK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6585 LUANA AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2404
Mailing Address - Country:US
Mailing Address - Phone:773-991-3661
Mailing Address - Fax:
Practice Address - Street 1:30150 TELEGRAPH RD STE 245
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:248-605-3525
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008523103TC0700X
MI6301014853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical