Provider Demographics
NPI:1396428405
Name:LUTSEY, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LUTSEY
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 1:27666 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4897
Mailing Address - Country:US
Mailing Address - Phone:313-400-1626
Mailing Address - Fax:
Practice Address - Street 1:412 CENTURY LN
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4285
Practice Address - Country:US
Practice Address - Phone:616-396-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent