Healthcare Provider Details

I. General information

NPI: 1619389731
Provider Name (Legal Business Name): KELLY LORENZ MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18356 MYRTLE CT UNIT 4
LANSING IL
60438-3342
US

IV. Provider business mailing address

18356 MYRTLE CT UNIT 4
LANSING IL
60438-3342
US

V. Phone/Fax

Practice location:
  • Phone: 219-381-5791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: