Provider Demographics
NPI:1356852032
Name:BILLINGSLEY, LAUREN (MA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BILLINGSLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CROSS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8442
Mailing Address - Country:US
Mailing Address - Phone:904-307-0636
Mailing Address - Fax:
Practice Address - Street 1:997 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3311
Practice Address - Country:US
Practice Address - Phone:904-647-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-78728106S00000X
FLSA16826235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician