MEDICARE: MR. LORENZO D TATIS

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	103T00000X	Psychologist		NY

General Provider Information

NPI Number	:	1760745715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LORENZO D TATIS

Provider Business Mailing Address
First Line	:	3965 SEDGWICK AVE APT 14D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3115
Country	:	US
Telephone Number	:	718-796-6471
Fax Number	:

Provider Business Practice Location Address
First Line	:	3965 SEDGWICK AVE APT 14D
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3115
Country	:	US
Telephone Number	:	718-796-6471
Fax Number	:

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

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	07/21/2022

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