Provider Demographics
NPI:1942589627
Name:BLOUGH, MARK LEE (PSYD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEE
Last Name:BLOUGH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:718 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7815
Mailing Address - Country:US
Mailing Address - Phone:734-240-8400
Mailing Address - Fax:734-240-4450
Practice Address - Street 1:700 STEWART RD
Practice Address - Street 2:STE 105
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-5304
Practice Address - Country:US
Practice Address - Phone:734-240-1765
Practice Address - Fax:734-240-1787
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist