Provider Demographics
NPI:1568855617
Name:SCOVILL, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SCOVILL
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 1:325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 SPRING ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1105
Practice Address - Country:US
Practice Address - Phone:618-282-5172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0036972255A2300X
MO20140308362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer