=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104552140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ANN LENTZ LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2022
-----------------------------------------------------
Last Update Date | 04/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 MAIN ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-9893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-519-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 381 N 400 E
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-9705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-765-2836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 35002121A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------