Provider Demographics
NPI:1093920894
Name:FLORELL, DAN (PHD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:FLORELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1059
Mailing Address - Country:US
Mailing Address - Phone:859-624-2454
Mailing Address - Fax:859-624-2454
Practice Address - Street 1:1421 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1059
Practice Address - Country:US
Practice Address - Phone:859-624-2454
Practice Address - Fax:859-624-2454
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129219103TS0200X
KY1337103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000676503OtherANTHEM PIN
KYP400027059Medicare PIN
000000676503OtherANTHEM PIN