Basic Information
| Provider Information | |||||||||
| NPI: | 1235396607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORY | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIBLE | ||||||||
| OtherFirstName: | ELISSA | ||||||||
| OtherMiddleName: | FORY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 425 W 59TH ST | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100198022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125236521 | ||||||||
| FaxNumber: | 2125236962 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD # K-11 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
| FaxNumber: | 3139165117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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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 | 2084N0400X | 4301115381 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.