Provider Demographics
NPI:1508275330
Name:LIETAERT, LAUREN (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:LIETAERT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16645 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2206
Mailing Address - Country:US
Mailing Address - Phone:586-213-5505
Mailing Address - Fax:586-213-5504
Practice Address - Street 1:16645 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2206
Practice Address - Country:US
Practice Address - Phone:586-213-5505
Practice Address - Fax:586-213-5504
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267461363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health