Provider Demographics
NPI:1356923429
Name:LORENZO-LUACES, LORENZO (PHD)
Entity type:Individual
Prefix:
First Name:LORENZO
Middle Name:
Last Name:LORENZO-LUACES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:LORENZO
Other - Middle Name:
Other - Last Name:LORENZO-LUACES VALENCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1101 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7007
Mailing Address - Country:US
Mailing Address - Phone:812-856-0866
Mailing Address - Fax:
Practice Address - Street 1:4401 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1822
Practice Address - Country:US
Practice Address - Phone:317-923-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043407A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20043407AOtherINDIANA STATE PSYCHOLOGY BOARD