Provider Demographics
NPI:1467084483
Name:LUKE, LAUREN O
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:O
Last Name:LUKE
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 1:90001 MILLER RD; SUITE #5
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473
Mailing Address - Country:US
Mailing Address - Phone:989-401-2244
Mailing Address - Fax:
Practice Address - Street 1:1070 RANGE RD
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4606
Practice Address - Country:US
Practice Address - Phone:810-937-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician