Healthcare Provider Details

I. General information

NPI: 1720330079
Provider Name (Legal Business Name): LORENA ESCORIAZA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 BROADWAY RM 718
NEW YORK NY
10012
US

IV. Provider business mailing address

611 BROADWAY RM 718
NEW YORK NY
10012-2649
US

V. Phone/Fax

Practice location:
  • Phone: 646-330-3005
  • Fax:
Mailing address:
  • Phone: 646-330-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019824
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: