Provider Demographics
NPI:1467999714
Name:BLAIR, LAUREN (BCABA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15023 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5024
Mailing Address - Country:US
Mailing Address - Phone:586-286-9644
Mailing Address - Fax:
Practice Address - Street 1:2221 LIVERNOIS RD
Practice Address - Street 2:STE 101
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1603
Practice Address - Country:US
Practice Address - Phone:248-554-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-15-05273106S00000X
MI7402000085103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician