MEDICARE: LORI LYNNE FRY BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-14-16273

General Provider Information

NPI Number	:	1336528462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI LYNNE FRY BCBA

Provider Business Mailing Address
First Line	:	912 ALGER ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3804
Country	:	US
Telephone Number	:	574-904-9433
Fax Number	:

Provider Business Practice Location Address
First Line	:	912 ALGER ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3804
Country	:	US
Telephone Number	:	574-904-9433
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2015
Last Update Date	:	02/27/2024

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