Provider Demographics
NPI:1568008456
Name:LORA-ACOSTA, RENNY
Entity Type:Individual
Prefix:
First Name:RENNY
Middle Name:
Last Name:LORA-ACOSTA
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 1:233 MAIN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 DOMINICS CT
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1574
Practice Address - Country:US
Practice Address - Phone:860-329-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5486101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional