Healthcare Provider Details

I. General information

NPI: 1255585436
Provider Name (Legal Business Name): LORI BOOTHROYD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12935 S WEST BAY SHORE DR SUITE 200
TRAVERSE CITY MI
49684-6298
US

IV. Provider business mailing address

13351 S PARTRIDGE RUN DR
TRAVERSE CITY MI
49684-8485
US

V. Phone/Fax

Practice location:
  • Phone: 231-929-4722
  • Fax:
Mailing address:
  • Phone: 231-929-4722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301012397
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6301012397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: