Provider Demographics
NPI:1265511042
Name:FAIRBANKS, LAUREN (LOTR, CHT)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:LOTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17709 OLD JEFFERSON HWY STE A
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3977
Mailing Address - Country:US
Mailing Address - Phone:225-677-8400
Mailing Address - Fax:225-677-8484
Practice Address - Street 1:17709 OLD JEFFERSON HWY STE A
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3977
Practice Address - Country:US
Practice Address - Phone:225-677-8400
Practice Address - Fax:225-677-8484
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10470225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA212607OtherCOVENTRY
LA212607OtherCOVENTRY