Provider Demographics
NPI:1083707137
Name:MASTROGIANIS, LAURIE BURDA (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:BURDA
Last Name:MASTROGIANIS
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:DR
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:MASTROGIANIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:63959 INVERNESS DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2850
Mailing Address - Country:US
Mailing Address - Phone:586-540-1094
Mailing Address - Fax:
Practice Address - Street 1:44056 MOUND RD 105
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1357
Practice Address - Country:US
Practice Address - Phone:586-540-1094
Practice Address - Fax:586-816-0154
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013176103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17102796017Medicare PIN