Provider Demographics
NPI:1922403823
Name:CANTWELL, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 ALBERT LONG DR
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-2472
Mailing Address - Country:US
Mailing Address - Phone:540-432-8660
Mailing Address - Fax:
Practice Address - Street 1:3270 ALBERT LONG DR
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-2472
Practice Address - Country:US
Practice Address - Phone:540-432-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040076921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12761071OtherCAQH
VA1154602639Medicaid