Provider Demographics
NPI:1871772699
Name:WERRES, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WERRES
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 1:300 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-4360
Mailing Address - Fax:920-437-3540
Practice Address - Street 1:1500 W ROGERS AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5007
Practice Address - Country:US
Practice Address - Phone:920-954-6804
Practice Address - Fax:920-954-6806
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40906900Medicaid