Provider Demographics
NPI:1124116256
Name:LORE, WESLEY WILLIAM (MA)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:WILLIAM
Last Name:LORE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16487
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-7002
Mailing Address - Country:US
Mailing Address - Phone:484-330-1837
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 16487
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-7002
Practice Address - Country:US
Practice Address - Phone:484-330-1837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional