Provider Demographics
NPI:1033367255
Name:LORENZO-BLANCO, ELMA INES
Entity Type:Individual
Prefix:
First Name:ELMA
Middle Name:INES
Last Name:LORENZO-BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 JONES DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1871
Mailing Address - Country:US
Mailing Address - Phone:734-383-0917
Mailing Address - Fax:
Practice Address - Street 1:1551 JONES DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1871
Practice Address - Country:US
Practice Address - Phone:734-383-0917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical