Healthcare Provider Details

I. General information

NPI: 1255521787
Provider Name (Legal Business Name): BLAKE M LANCASTER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MAYNARD ST STE 402
ANN ARBOR MI
48104-2282
US

IV. Provider business mailing address

333 MAYNARD ST STE 402
ANN ARBOR MI
48104-2282
US

V. Phone/Fax

Practice location:
  • Phone: 269-998-1005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPLP302
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015156
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301015156
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: