Provider Demographics
NPI:1710210513
Name:JIM, LORENZO R (LADAC)
Entity Type:Individual
Prefix:MR
First Name:LORENZO
Middle Name:R
Last Name:JIM
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5608 ZUNI RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2926
Mailing Address - Country:US
Mailing Address - Phone:505-262-2481
Mailing Address - Fax:505-265-7045
Practice Address - Street 1:5608 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2926
Practice Address - Country:US
Practice Address - Phone:505-262-2481
Practice Address - Fax:505-265-7045
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0125371101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0125371OtherSTATE LICENSE