Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | CP00001048 | WA |
NPI | 1073083580 |
---|---|
Provider Name | Melody Kay Lorenzo |
First Address | Kelso, WA 98626-1118 |
Second Address | Kelso, WA 98626-1118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/11/2018 |
Last Update Date | 27/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1801018528 | (05) | WA |