Provider Demographics
NPI:1255585436
Name:BOOTHROYD, LORI (PHD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:BOOTHROYD
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 1:13351 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:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012397103TC1900X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1793Medicare PIN