Provider Demographics
NPI:1881184141
Name:MOBERG, LAUREN (DAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MOBERG
Suffix:
Gender:F
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 N SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3290
Mailing Address - Country:US
Mailing Address - Phone:763-447-1583
Mailing Address - Fax:
Practice Address - Street 1:2323 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3290
Practice Address - Country:US
Practice Address - Phone:762-447-1583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL59682255A2300X
390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program