Healthcare Provider Details

I. General information

NPI: 1033367255
Provider Name (Legal Business Name): ELMA INES LORENZO-BLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 JONES DR
ANN ARBOR MI
48105-1871
US

IV. Provider business mailing address

1551 JONES DR
ANN ARBOR MI
48105-1871
US

V. Phone/Fax

Practice location:
  • Phone: 734-383-0917
  • Fax:
Mailing address:
  • Phone: 734-383-0917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number390200000X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: