Healthcare Provider Details

I. General information

NPI: 1518724566
Provider Name (Legal Business Name): LORI LADY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 IDA ST
POPLAR BLUFF MO
63901-4210
US

IV. Provider business mailing address

936 IDA ST
POPLAR BLUFF MO
63901-4210
US

V. Phone/Fax

Practice location:
  • Phone: 573-300-4597
  • Fax: 573-300-4612
Mailing address:
  • Phone: 573-300-4597
  • Fax: 573-300-4612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2026009286
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: