Provider Demographics
NPI:1003197245
Name:BLAKE-DUNCAN, LYNEAH R (TLLP)
Entity type:Individual
Prefix:MS
First Name:LYNEAH
Middle Name:R
Last Name:BLAKE-DUNCAN
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 N SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229 N SHELDON RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:313-278-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103T00000X
MI6301015236251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No251S00000XAgenciesCommunity/Behavioral Health