Provider Demographics
NPI:1043234859
Name:LOURIE, IRA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:LOURIE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-584-0240
Mailing Address - Fax:248-584-0241
Practice Address - Street 1:28220 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1659
Practice Address - Country:US
Practice Address - Phone:248-788-9708
Practice Address - Fax:248-788-9708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI630100750103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist