Provider Demographics
NPI:1508520396
Name:DEBERTIN, LAUREN MICHELLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:DEBERTIN
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 1:6191 S 108TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2524
Mailing Address - Country:US
Mailing Address - Phone:414-475-1896
Mailing Address - Fax:414-988-9764
Practice Address - Street 1:6191 S 108TH ST STE B
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2524
Practice Address - Country:US
Practice Address - Phone:414-475-1896
Practice Address - Fax:414-988-9764
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI459-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100087705Medicaid