Provider Demographics
NPI:1043092729
Name:MORAN, LORIE HERTZLER
Entity type:Individual
Prefix:
First Name:LORIE
Middle Name:HERTZLER
Last Name:MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 SASHABAW RD STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2269
Mailing Address - Country:US
Mailing Address - Phone:248-496-0696
Mailing Address - Fax:
Practice Address - Street 1:6300 SASHABAW RD STE B
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2269
Practice Address - Country:US
Practice Address - Phone:248-496-0696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010768711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical