Basic Information
| Provider Information | |||||||||
| NPI: | 1245249317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCY | ||||||||
| FirstName: | LA WANDA | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROUNTREE | ||||||||
| OtherFirstName: | LA WANDA | ||||||||
| OtherMiddleName: | FAY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15890 SUSSEX ST | ||||||||
| Address2: | N/A | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482272661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138375782 | ||||||||
| FaxNumber: | 3133965353 | ||||||||
| Practice Location | |||||||||
| Address1: | 2939 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | 3133965353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 06/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801086293 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.