MEDICARE: MR. ARLO LAURENTZ LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	3460	LA
2	171M00000X	Case Manager/Care Coordinator	1618	LA

General Provider Information

NPI Number	:	1912355736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ARLO LAURENTZ LAC

Provider Business Mailing Address
First Line	:	1639 RYAN ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5948
Country	:	US
Telephone Number	:	337-602-6391
Fax Number	:

Provider Business Practice Location Address
First Line	:	1639 RYAN ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5948
Country	:	US
Telephone Number	:	337-602-6391
Fax Number	:

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

Provider Enumeration Date	:	06/02/2016
Last Update Date	:	10/01/2019

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