Provider Demographics
NPI:1568668077
Name:PHAN, LORI (MA, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 SEWELL DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4124
Mailing Address - Country:US
Mailing Address - Phone:502-655-8105
Mailing Address - Fax:
Practice Address - Street 1:11110 SEWELL DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4124
Practice Address - Country:US
Practice Address - Phone:502-655-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100299103K00000X
KYKY-0040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100325870Medicaid