1306978556 NPI number — LISA MICHELLE LOURY LOMAS LCPC

Table of content: LISA MICHELLE LOURY LOMAS LCPC (NPI 1306978556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306978556 NPI number — LISA MICHELLE LOURY LOMAS LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOURY LOMAS
Provider First Name:
LISA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306978556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 E 162ND ST
Provider Second Line Business Mailing Address:
#153
Provider Business Mailing Address City Name:
SOUTH HOLLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60473-2258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-772-0499
Provider Business Mailing Address Fax Number:
410-772-0599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 E 162ND ST
Provider Second Line Business Practice Location Address:
#153
Provider Business Practice Location Address City Name:
SOUTH HOLLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60473-2258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-772-0499
Provider Business Practice Location Address Fax Number:
410-772-0599
Provider Enumeration Date:
03/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  PRC13886 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)