Basic Information
| Provider Information | |||||||||
| NPI: | 1992146617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUME | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20418 LICHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482211332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345168006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11111 HALL RD STE 303 | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483175726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869973153 | ||||||||
| FaxNumber: | 5869974956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2013 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401013733 | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 6401013733 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401013733 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.