MEDICARE: MRS. LORI RACHEL BROWN B.S.

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1912165473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI RACHEL BROWN B.S.

Provider Business Mailing Address
First Line	:	1302 VALDOSTA DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3526
Country	:	US
Telephone Number	:	260-489-1628
Fax Number	:	260-489-1628

Provider Business Practice Location Address
First Line	:	1302 VALDOSTA DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3526
Country	:	US
Telephone Number	:	260-489-1628
Fax Number	:	260-489-1628

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

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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