Healthcare Provider Details

I. General information

NPI: 1477893220
Provider Name (Legal Business Name): LAURIE A LUNDBLAD PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9357 GENERAL DR SUITE 101
PLYMOUTH MI
48170-4662
US

IV. Provider business mailing address

9357 GENERAL DR SUITE 101
PLYMOUTH MI
48170-4662
US

V. Phone/Fax

Practice location:
  • Phone: 734-454-0866
  • Fax: 734-454-1744
Mailing address:
  • Phone: 734-454-0866
  • Fax: 734-454-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301013693
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: