Provider Demographics
NPI:1124554159
Name:DALTON-TRUSTY, LUCETRY (PSYD)
Entity type:Individual
Prefix:DR
First Name:LUCETRY
Middle Name:
Last Name:DALTON-TRUSTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LUCETRY
Other - Middle Name:BIANCHI
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:5425 GULLEN MALL OFC 343
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3905
Mailing Address - Country:US
Mailing Address - Phone:248-421-3524
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1802
Practice Address - Country:US
Practice Address - Phone:313-777-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist