Provider Demographics
NPI:1043973944
Name:WAY, LORI (MA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 W 8TH ST APT 112
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4500
Mailing Address - Country:US
Mailing Address - Phone:310-525-0495
Mailing Address - Fax:
Practice Address - Street 1:3939 ATLANTIC AVE STE 102
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3535
Practice Address - Country:US
Practice Address - Phone:562-249-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126392106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist