Provider Demographics
NPI:1437328200
Name:MARR, IDA B (LPP)
Entity type:Individual
Prefix:MS
First Name:IDA
Middle Name:B
Last Name:MARR
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:859-288-2392
Mailing Address - Fax:859-721-2572
Practice Address - Street 1:1113 CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-3208
Practice Address - Country:US
Practice Address - Phone:859-288-2425
Practice Address - Fax:859-721-2572
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0062103TC0700X
KY115837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid