MEDICARE: DR. LOLA WINN O'RENICK PH.D.

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	01736	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22009014	OTHER	MO	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699768846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOLA WINN O'RENICK PH.D.

Provider Business Mailing Address
First Line	:	1004 SW 22ND ST
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-4752
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 SW 22ND ST
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-4752
Country	:	US
Telephone Number	:	816-456-4252
Fax Number	:

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	11/17/2012

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