Provider Demographics
NPI:1700197886
Name:ROELOFS, LORI LYNN (MPT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:ROELOFS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CLEMENTINE ST
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-5303
Mailing Address - Country:US
Mailing Address - Phone:949-422-7839
Mailing Address - Fax:949-713-0110
Practice Address - Street 1:20902 BAKE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2175
Practice Address - Country:US
Practice Address - Phone:949-600-5437
Practice Address - Fax:949-600-5439
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254552251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT254550OtherBLUE CROSS PROVIDER ID