MEDICARE: DR. LORI LICHTMAN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301010154	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680H148340	OTHER	MI	BCBS OF MI
2	680H107900	OTHER	MI	BCBS OF MI
3	680H118950	OTHER	MI	BCBS OF MI

General Provider Information

NPI Number	:	1851307805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORI LICHTMAN PSYD

Provider Business Mailing Address
First Line	:	2395 OAK VALLEY DR
Second Line	:	SUITE 100
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-9118
Country	:	US
Telephone Number	:	734-995-5181
Fax Number	:	734-995-9011

Provider Business Practice Location Address
First Line	:	2395 OAK VALLEY DR
Second Line	:	SUITE 100
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-9118
Country	:	US
Telephone Number	:	734-995-5181
Fax Number	:	734-995-9011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	04/17/2013

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