Provider Demographics
NPI:1154072924
Name:LORETZ, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LORETZ
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 1:20 ROLLING HILL DR
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-6514
Mailing Address - Country:US
Mailing Address - Phone:631-241-8735
Mailing Address - Fax:631-286-2364
Practice Address - Street 1:20 ROLLING HILL DR
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-6514
Practice Address - Country:US
Practice Address - Phone:631-241-8735
Practice Address - Fax:631-286-2364
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-03-06
Deactivation Date:2022-01-18
Deactivation Code:
Reactivation Date:2022-02-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty