Provider Demographics
NPI:1194906347
Name:FRIESTROM, LORI (MDIVPC, LMFT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:FRIESTROM
Suffix:
Gender:F
Credentials:MDIVPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 PERIMETER DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8866
Mailing Address - Country:US
Mailing Address - Phone:502-741-8425
Mailing Address - Fax:
Practice Address - Street 1:3101 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8866
Practice Address - Country:US
Practice Address - Phone:502-741-8425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0668106H00000X
IN35001619A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist