MEDICARE: LORELI LEOS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	61298	TX

General Provider Information

NPI Number	:	1689870230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORELI LEOS LPC

Provider Business Mailing Address
First Line	:	5764 N MESA ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-5427
Country	:	US
Telephone Number	:	915-240-8409
Fax Number	:

Provider Business Practice Location Address
First Line	:	5764 N MESA ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-5427
Country	:	US
Telephone Number	:	915-240-8409
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	05/02/2014

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