Healthcare Provider Details

I. General information

NPI: 1558020669
Provider Name (Legal Business Name): LORRENZO L ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 LEXINGTON AVE
SPRINGFIELD OH
45505-2620
US

IV. Provider business mailing address

2624 LEXINGTON AVE
SPRINGFIELD OH
45505-2620
US

V. Phone/Fax

Practice location:
  • Phone: 937-328-5300
  • Fax: 937-322-4900
Mailing address:
  • Phone: 937-328-5300
  • Fax: 937-322-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.002340
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.180288
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: