Provider Demographics
NPI:1639269384
Name:MANCHESTER, LAUREN S (LADC)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:S
Last Name:MANCHESTER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:MRS
Other - First Name:LAURIE
Other - Middle Name:S
Other - Last Name:MANCHESTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LADC
Mailing Address - Street 1:650 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5448
Mailing Address - Country:US
Mailing Address - Phone:207-774-4564
Mailing Address - Fax:207-774-0006
Practice Address - Street 1:650 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5448
Practice Address - Country:US
Practice Address - Phone:207-774-4564
Practice Address - Fax:207-774-0006
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC2767101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)