Provider Demographics
NPI:1982148730
Name:BROOKHART, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BROOKHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 YANKEE PARK PL
Mailing Address - Street 2:SUITE P
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1959
Mailing Address - Country:US
Mailing Address - Phone:937-952-5011
Mailing Address - Fax:
Practice Address - Street 1:1458 YANKEE PARK PL
Practice Address - Street 2:SUITE P
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-1959
Practice Address - Country:US
Practice Address - Phone:937-952-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.111003101YA0400X
OHE.1300082101YM0800X
OHS.0800395104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker