Provider Demographics
NPI:1508001090
Name:LORI GRAY BOOTHROYD PLLC
Entity Type:Organization
Organization Name:LORI GRAY BOOTHROYD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTHROYD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-929-4722
Mailing Address - Street 1:13351 S PARTRIDGE RUN DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8485
Mailing Address - Country:US
Mailing Address - Phone:231-929-4722
Mailing Address - Fax:
Practice Address - Street 1:12935 S WEST BAY SHORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6298
Practice Address - Country:US
Practice Address - Phone:231-929-4722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012397251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1793Medicare PIN