Basic Information
| Provider Information | |||||||||
| NPI: | 1851367361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PHD HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465289365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 09/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20040808A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200200760A | 05 | IN | MEDICAID |