Provider Demographics
NPI:1215152517
Name:BURRUEL-HOMA, LORI JEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:JEAN
Last Name:BURRUEL-HOMA
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 1:1250 E BASELINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1436
Mailing Address - Country:US
Mailing Address - Phone:480-775-3774
Mailing Address - Fax:480-831-0256
Practice Address - Street 1:1250 E BASELINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1436
Practice Address - Country:US
Practice Address - Phone:480-775-3774
Practice Address - Fax:480-831-0256
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical