Healthcare Provider Details

I. General information

NPI: 1669719779
Provider Name (Legal Business Name): ASHLEY E LUPICO M.A, TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY E WANCOUR M.A., TLLP

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42140 VAN DYKE AVE STE 210
STERLING HEIGHTS MI
48314-3676
US

IV. Provider business mailing address

52456 FAYETTE DR
SHELBY TOWNSHIP MI
48316-3054
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 586-246-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015309
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: