Provider Demographics
NPI:1326635020
Name:FORNER, LAUREN M
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:FORNER
Suffix:
Gender:F
Credentials:
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 254
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0254
Mailing Address - Country:US
Mailing Address - Phone:269-615-8209
Mailing Address - Fax:
Practice Address - Street 1:600 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1354
Practice Address - Country:US
Practice Address - Phone:269-615-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst