Provider Demographics
NPI:1902414329
Name:LORENZO, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:LORENZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13955 NW 22ND PL
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-4005
Mailing Address - Country:US
Mailing Address - Phone:786-307-4538
Mailing Address - Fax:
Practice Address - Street 1:13955 NW 22ND PL
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-4005
Practice Address - Country:US
Practice Address - Phone:786-307-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-122048106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician