Provider Demographics
NPI:1366843633
Name:LOR, KEVIN C (PC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:C
Last Name:LOR
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:N158 STATE PARK RD APT 4
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-8788
Mailing Address - Country:US
Mailing Address - Phone:920-585-8397
Mailing Address - Fax:920-832-4767
Practice Address - Street 1:401 S ELM ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5900
Practice Address - Country:US
Practice Address - Phone:920-832-4646
Practice Address - Fax:920-832-4767
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3834-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional