Provider Demographics
NPI:1619253812
Name:PETA, LORENE RENEE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:LORENE
Middle Name:RENEE
Last Name:PETA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1055 E BALTIMORE PIKE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5173
Mailing Address - Country:US
Mailing Address - Phone:610-892-3800
Mailing Address - Fax:484-468-1412
Practice Address - Street 1:2010 W CHESTER PIKE
Practice Address - Street 2:SUITE 314
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2700
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:484-468-1412
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPC001204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional