Provider Demographics
NPI:1013392364
Name:AMPOLOS, LAUREN ELAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ELAINE
Last Name:AMPOLOS
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 1:415 DAIRY RD STE E-323
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2348
Mailing Address - Country:US
Mailing Address - Phone:808-518-1619
Mailing Address - Fax:
Practice Address - Street 1:415 DAIRY RD STE E-323
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2348
Practice Address - Country:US
Practice Address - Phone:808-518-1619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1555103TH0004X, 103TP2701X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral