Provider Demographics
NPI:1861852659
Name:LORENZ, CHANTELLE (CMT)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:
Last Name:LORENZ
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 MARIPOSA AVE
Mailing Address - Street 2:#102
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1364
Mailing Address - Country:US
Mailing Address - Phone:510-463-4330
Mailing Address - Fax:
Practice Address - Street 1:2930 MCCLURE ST
Practice Address - Street 2:#4
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3556
Practice Address - Country:US
Practice Address - Phone:510-463-4330
Practice Address - Fax:510-465-4807
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist