Provider Demographics
NPI:1205434578
Name:CHANG, LORENA G (MT)
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:G
Last Name:CHANG
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1400
Mailing Address - Country:US
Mailing Address - Phone:212-227-3233
Mailing Address - Fax:
Practice Address - Street 1:610 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1400
Practice Address - Country:US
Practice Address - Phone:212-227-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18KT01377300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ18KT01377300OtherMASSAGE THERAPY