Provider Demographics
NPI:1861000978
Name:FONTENOT, LAUREN GAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:GAY
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 TINDAL AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2839
Mailing Address - Country:US
Mailing Address - Phone:706-207-3511
Mailing Address - Fax:
Practice Address - Street 1:3453 PELHAM RD STE 107
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-7400
Practice Address - Country:US
Practice Address - Phone:864-800-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical