Healthcare Provider Details

I. General information

NPI: 1548684640
Provider Name (Legal Business Name): LORI GEVEDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5954 LONGFORD RD
HUBER HEIGHTS OH
45424-2943
US

IV. Provider business mailing address

3110 TURTLEBROOK CT
DAYTON OH
45414-1783
US

V. Phone/Fax

Practice location:
  • Phone: 937-237-6345
  • Fax: 937-237-6307
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberUD1005280
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: