Provider Demographics
NPI:1699896530
Name:BLALOCK, LUTRINO MARCELL (MA LPA)
Entity type:Individual
Prefix:MS
First Name:LUTRINO
Middle Name:MARCELL
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:MA LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10716 LOWERY DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-9714
Mailing Address - Country:US
Mailing Address - Phone:919-604-0918
Mailing Address - Fax:
Practice Address - Street 1:1100 LOGGER CT
Practice Address - Street 2:SUITE F100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8511
Practice Address - Country:US
Practice Address - Phone:919-604-0918
Practice Address - Fax:919-847-6120
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2493103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107073Medicaid