Provider Demographics
NPI:1659412153
Name:ST. AMOUR, LAUREN E (LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:ST. AMOUR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:E
Other - Last Name:FAUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 JOYCE ST
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2947
Mailing Address - Country:US
Mailing Address - Phone:617-416-0597
Mailing Address - Fax:
Practice Address - Street 1:47 WATER ST STE 202
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2573
Practice Address - Country:US
Practice Address - Phone:617-416-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW017651041C0700X
CT0068191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
007059145OtherMEDICARE
RILF65486Medicaid
600052-721OtherMAGELLAN
31443-5OtherBLUE CROSS BLUE SHIELD
413425OtherBLUE CHIP
1021740OtherGROUP NHP