Provider Demographics
NPI:1770122384
Name:LO, LAWRENCE VON (REG COUNSELOR)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:VON
Last Name:LO
Suffix:
Gender:M
Credentials:REG COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8828 KELLEY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2124
Mailing Address - Country:US
Mailing Address - Phone:209-817-5907
Mailing Address - Fax:
Practice Address - Street 1:1111 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1305
Practice Address - Country:US
Practice Address - Phone:209-938-0228
Practice Address - Fax:209-938-0281
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA10180101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)