Healthcare Provider Details

I. General information

NPI: 1003584822
Provider Name (Legal Business Name): MARGARET GRACE LORELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD STE 209
ORLANDO FL
32819-4206
US

IV. Provider business mailing address

770 MARYLAND AVE
WINTER PARK FL
32789-5042
US

V. Phone/Fax

Practice location:
  • Phone: 321-732-3723
  • Fax:
Mailing address:
  • Phone: 813-244-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT21183725
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: