Healthcare Provider Details

I. General information

NPI: 1013624618
Provider Name (Legal Business Name): LUMATE FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 CATRINA LN
ANNAPOLIS MD
21403-4343
US

IV. Provider business mailing address

822 GUILFORD AVE # 1500
BALTIMORE MD
21202-3707
US

V. Phone/Fax

Practice location:
  • Phone: 917-304-0679
  • Fax:
Mailing address:
  • Phone: 800-402-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: RUSH MCCLOY
Title or Position: CEO
Credential:
Phone: 917-304-0679