Provider Demographics
NPI:1922151927
Name:PETRIE, LORI M (PHD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:PETRIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:M
Other - Last Name:GREBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:235 RUBY CT
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3393
Mailing Address - Country:US
Mailing Address - Phone:310-650-1232
Mailing Address - Fax:
Practice Address - Street 1:4305 TORRANCE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4409
Practice Address - Country:US
Practice Address - Phone:310-650-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12329103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist