Provider Demographics
NPI:1174744718
Name:KHURI, MARY LYDIA
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYDIA
Last Name:KHURI
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:LYDIA
Other - Last Name:KHURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:106 N. FAIR STREET
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821
Mailing Address - Country:US
Mailing Address - Phone:217-366-8360
Mailing Address - Fax:
Practice Address - Street 1:202 W. GREEN STREET
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-328-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical