Basic Information
| Provider Information | |||||||||
| NPI: | 1225503741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TELLERIA | ||||||||
| FirstName: | LORENZO | ||||||||
| MiddleName: | ANDRES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST STE 1899 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913674976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11606 SOUTHFORK AVE STE 300B | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708165235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252925981 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 8701343320272 | 05 | LA | MEDICAID |