Provider Demographics
NPI:1861039968
Name:MCGRUDER, LORI LYNN (NCC, LMHC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:MCGRUDER
Suffix:
Gender:F
Credentials:NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 NW 120TH WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-5273
Mailing Address - Country:US
Mailing Address - Phone:352-316-5620
Mailing Address - Fax:
Practice Address - Street 1:1607 NW 120TH WAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-5273
Practice Address - Country:US
Practice Address - Phone:352-316-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH8492OtherDEPARTMENT OF HEALTH