Provider Demographics
NPI:1497123780
Name:SECULOFF, LAUREN THERESE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:THERESE
Last Name:SECULOFF
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:THERESE
Other - Last Name:ROSSWURM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:10445 DUPONT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8792
Mailing Address - Country:US
Mailing Address - Phone:260-205-8584
Mailing Address - Fax:
Practice Address - Street 1:10445 DUPONT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8792
Practice Address - Country:US
Practice Address - Phone:260-205-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002823A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist