Healthcare Provider Details

I. General information

NPI: 1508781071
Provider Name (Legal Business Name): LORI BOGARD-CUSACK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 W HOWELL RD
MASON MI
48854-9392
US

IV. Provider business mailing address

4423 POTTERS RD
IONIA MI
48846-9541
US

V. Phone/Fax

Practice location:
  • Phone: 517-676-1051
  • Fax:
Mailing address:
  • Phone: 419-310-1734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: