Provider Demographics
NPI:1790716520
Name:DICKIE, LAUREN RENAYE LEFAVOR (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:RENAYE LEFAVOR
Last Name:DICKIE
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:DR
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:LEFAVOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD LP
Mailing Address - Street 1:108 S MINNESOTA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-2557
Mailing Address - Country:US
Mailing Address - Phone:507-721-1227
Mailing Address - Fax:
Practice Address - Street 1:108 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082
Practice Address - Country:US
Practice Address - Phone:507-934-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3919103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680002156Medicare PIN