Provider Demographics
NPI:1376070490
Name:LORD, ANTHONY AADOLPHUS I
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:AADOLPHUS
Last Name:LORD
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 ELM DR APT 3
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3133
Mailing Address - Country:US
Mailing Address - Phone:415-320-2489
Mailing Address - Fax:415-492-0834
Practice Address - Street 1:1140 ELM DR APT 3
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3133
Practice Address - Country:US
Practice Address - Phone:415-320-2489
Practice Address - Fax:415-492-0834
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-CAZSPQ175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN5836204Medicaid