Provider Demographics
NPI:1699768846
Name:O'RENICK, LOLA WINN (PHD)
Entity type:Individual
Prefix:DR
First Name:LOLA WINN
Middle Name:
Last Name:O'RENICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 SW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-4752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 SW 22ND ST
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-4752
Practice Address - Country:US
Practice Address - Phone:816-456-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01736103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22009014OtherBLUE CROSS BLUE SHIELD
MO498502400Medicaid
MO758502405Medicaid
MO498502400Medicaid