Healthcare Provider Details

I. General information

NPI: 1982900510
Provider Name (Legal Business Name): LORENZ CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2011
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1772 STEIGER LAKE LN SUITE 220
VICTORIA MN
55386-7723
US

IV. Provider business mailing address

PO BOX 51 1772 STIEGER LAKE LANE SUITE 220
VICTORIA MN
55386-0051
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-4600
  • Fax: 952-443-4604
Mailing address:
  • Phone: 952-443-4600
  • Fax: 952-443-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLP5754
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1764
License Number StateMN

VIII. Authorized Official

Name: DR. CHAD T. LORENZ
Title or Position: OWNER
Credential: PSY.D.
Phone: 952-443-4600