Provider Demographics
NPI:1386710317
Name:BRAY, LORI M (PH D LLP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:BRAY
Suffix:
Gender:F
Credentials:PH D LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 NORTHLAND DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1040
Mailing Address - Country:US
Mailing Address - Phone:616-361-5001
Mailing Address - Fax:616-361-2166
Practice Address - Street 1:5250 NORTHLAND DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1040
Practice Address - Country:US
Practice Address - Phone:616-361-5001
Practice Address - Fax:616-361-2166
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013416103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist