Provider Demographics
NPI:1245252378
Name:BEN-EZRA, LORI A (PHD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:A
Last Name:BEN-EZRA
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 1:9900 STIRLING RD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-8065
Mailing Address - Country:US
Mailing Address - Phone:954-364-6294
Mailing Address - Fax:954-364-6293
Practice Address - Street 1:9900 STIRLING RD
Practice Address - Street 2:SUITE 217
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-8065
Practice Address - Country:US
Practice Address - Phone:954-364-6294
Practice Address - Fax:954-364-6293
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5295103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59780Medicare ID - Type Unspecified