Provider Demographics
NPI:1851483929
Name:SIMON, LORI (EDDPCC)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:EDDPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4339 WINSTON AVE
Mailing Address - Street 2:LATONIA CENTRE
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1739
Mailing Address - Country:US
Mailing Address - Phone:859-835-2573
Mailing Address - Fax:859-727-6327
Practice Address - Street 1:4339 WINSTON AVE
Practice Address - Street 2:LATONIA CENTRE
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1739
Practice Address - Country:US
Practice Address - Phone:859-835-2573
Practice Address - Fax:859-727-6327
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY405101YP2500X
KY105701101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000379463OtherANTHEMBC/BS ID