Provider Demographics
NPI:1407599475
Name:MCILVANIE, LAUREN MARY
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARY
Last Name:MCILVANIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MARY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:713 DAWN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-8402
Mailing Address - Country:US
Mailing Address - Phone:319-573-3830
Mailing Address - Fax:
Practice Address - Street 1:10184 E I25 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-5445
Practice Address - Country:US
Practice Address - Phone:720-378-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist