Provider Demographics
NPI:1326568338
Name:FAVREAU, LAUREN RENEE (DAC, LAC)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:RENEE
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:DAC, LAC
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:RENEE
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DAC, LAC
Mailing Address - Street 1:320 WINDHAM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4339
Mailing Address - Country:US
Mailing Address - Phone:914-494-5236
Mailing Address - Fax:
Practice Address - Street 1:60 PINELAND DR STE 203
Practice Address - Street 2:
Practice Address - City:NEW GLOUCESTER
Practice Address - State:ME
Practice Address - Zip Code:04260-5121
Practice Address - Country:US
Practice Address - Phone:207-808-9174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC576171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
167026OtherNCCAOM (NATIONAL CERTIFICATION COMMISSION FOR ACUPUNCTURE & ORIENTAL MEDICINE)