Provider Demographics
NPI:1649500059
Name:CHIDESTER, LORI ANN (BCABA)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:ANN
Last Name:CHIDESTER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 BAY COLT LN
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-8020
Mailing Address - Country:US
Mailing Address - Phone:513-861-0300
Mailing Address - Fax:513-861-0301
Practice Address - Street 1:170 E SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3803
Practice Address - Country:US
Practice Address - Phone:859-866-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003-1034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst