Provider Demographics
NPI:1639725161
Name:ROSSO, LAUREN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:
Last Name:ROSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 N OAK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1618
Mailing Address - Country:US
Mailing Address - Phone:479-601-2302
Mailing Address - Fax:
Practice Address - Street 1:19 E MOUNTAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6067
Practice Address - Country:US
Practice Address - Phone:479-308-8530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR18-18P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist