Provider Demographics
NPI:1164553715
Name:LORENCE DEL VALLE, LISA (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:LORENCE DEL VALLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 PARK SOUTH DR STE 510
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0100
Mailing Address - Country:US
Mailing Address - Phone:704-372-0670
Mailing Address - Fax:
Practice Address - Street 1:6135 PARK SOUTH DR STE 510
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0100
Practice Address - Country:US
Practice Address - Phone:704-372-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2373103T00000X
NCNC2373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0403WOtherBCBS INDIVIDUAL PROVIDER
NCD4319OtherMEDCOST INDIVIDUAL PROVID
NC0403WOtherBCBS INDIVIDUAL PROVIDER
NCD4319OtherMEDCOST INDIVIDUAL PROVID