Provider Demographics
NPI:1790765170
Name:REINEKE, LORI (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:REINEKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 RAYBROOK ST SE STE 308
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7717
Mailing Address - Country:US
Mailing Address - Phone:616-649-1010
Mailing Address - Fax:616-551-2895
Practice Address - Street 1:2020 RAYBROOK ST SE STE 308
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7717
Practice Address - Country:US
Practice Address - Phone:616-940-3331
Practice Address - Fax:616-551-2895
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MI6301009314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS29789Medicare UPIN
MI0M67310Medicare PIN