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General NPI Number Information
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NPI Number | 1699896530
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Entity Type | Individual
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Provider Name | LUTRINO MARCELL BLALOCK M.A. L.P.A.
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Gender | Female
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 11/18/2015
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Provider Practice Location Address
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Address Line | 1100 LOGGER CT SUITE F100
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City | RALEIGH
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State | NC
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Zip | 27609-8511
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Country | US
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Telephone | 919-604-0918
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Fax | 919-847-6120
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Provider Business Mailing Address
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Address Line | 10716 LOWERY DR
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City | RALEIGH
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State | NC
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Zip | 27615-9714
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Country | US
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Telephone | 919-604-0918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2493
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License Number State | NC
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