Provider Demographics
NPI:1629382783
Name:ABBOTT, LORRETTA JOY (MS)
Entity Type:Individual
Prefix:
First Name:LORRETTA
Middle Name:JOY
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 738
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94023-0738
Mailing Address - Country:US
Mailing Address - Phone:650-862-3054
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2142
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-31
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63851106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist