Healthcare Provider Details

I. General information

NPI: 1124502117
Provider Name (Legal Business Name): MISS LINA LORENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SHADOW LN STE 120
LAS VEGAS NV
89102-2342
US

IV. Provider business mailing address

1120 SHADOW LN STE 120
LAS VEGAS NV
89102-2342
US

V. Phone/Fax

Practice location:
  • Phone: 702-382-7746
  • Fax:
Mailing address:
  • Phone: 702-595-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9590-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: