Provider Demographics
NPI:1114415643
Name:BLANK, LORENA
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11857 FRANCIS SCOBEE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5084
Mailing Address - Country:US
Mailing Address - Phone:915-215-0214
Mailing Address - Fax:915-581-7980
Practice Address - Street 1:1368 N ZARAGOZA RD STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8030
Practice Address - Country:US
Practice Address - Phone:915-307-6721
Practice Address - Fax:915-581-7980
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional