Provider Demographics
NPI:1861608267
Name:LORENZ, JOHN R (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LORENZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 COLUMBIA ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6357
Mailing Address - Country:US
Mailing Address - Phone:207-942-8200
Mailing Address - Fax:207-990-3065
Practice Address - Street 1:82 COLUMBIA ST STE 301
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6357
Practice Address - Country:US
Practice Address - Phone:207-942-8200
Practice Address - Fax:207-990-3065
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS0000444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003591OtherANTHEM PIN
ME703684Medicare ID - Type Unspecified