=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821638073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI DZIEDZIAK LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 01/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 S WARNER RD
-----------------------------------------------------
City | KING OF PRUSSIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19406-2826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-304-3889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 736 S TRAPPE RD
-----------------------------------------------------
City | COLLEGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-304-3889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | PC006547
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------