Provider Demographics
NPI:1497899868
Name:IREY, LARRY DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DAVID
Last Name:IREY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9120
Mailing Address - Country:US
Mailing Address - Phone:269-207-7371
Mailing Address - Fax:
Practice Address - Street 1:4328 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5823
Practice Address - Country:US
Practice Address - Phone:269-353-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOC94528Medicare ID - Type Unspecified