=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609319516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLERINA LUMAJ MA,TLLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2016
-----------------------------------------------------
Last Update Date | 11/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11111 HALL RD
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-552-6268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47724 CONCORD RD
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-552-6268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301015739
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------