Provider Demographics
NPI:1871547653
Name:LUBAVS, AIJA (MA)
Entity type:Individual
Prefix:
First Name:AIJA
Middle Name:
Last Name:LUBAVS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1728
Mailing Address - Country:US
Mailing Address - Phone:269-343-3353
Mailing Address - Fax:269-344-8696
Practice Address - Street 1:5930 LOVERS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1673
Practice Address - Country:US
Practice Address - Phone:269-353-4370
Practice Address - Fax:269-344-8696
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008381103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP10893971OtherBLUE CROSS BLUE SHIELD
MIP10893971OtherBLUE CROSS BLUE SHIELD