MEDICARE: LORI KIM BRILL PSYD

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	103TC0700X	Clinical Psychologist	4055	AZ
2	103TC0700X	Clinical Psychologist	7796313-2501	UT

General Provider Information

NPI Number	:	1902139603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI KIM BRILL PSYD

Provider Business Mailing Address
First Line	:	3215 W RAPALO RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85086-2213
Country	:	US
Telephone Number	:	602-910-0526
Fax Number	:

Provider Business Practice Location Address
First Line	:	4150 W PEORIA AVE
Second Line	:	STE 133
City	:	PHOENIX
State	:	AZ
Zip	:	85029-3900
Country	:	US
Telephone Number	:	602-910-0526
Fax Number	:

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

Provider Enumeration Date	:	09/12/2009
Last Update Date	:	05/24/2015

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