Provider Demographics
NPI:1821541517
Name:BLANCK, LAUREN NICOLE (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:BLANCK
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3568
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-0141
Mailing Address - Country:US
Mailing Address - Phone:203-387-1401
Mailing Address - Fax:203-387-1451
Practice Address - Street 1:15 RESEARCH DR
Practice Address - Street 2:UNIT 1
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2356
Practice Address - Country:US
Practice Address - Phone:203-387-1401
Practice Address - Fax:203-387-1415
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist