Provider Demographics
NPI:1891440442
Name:BLANK, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 PUNTA TERSIVA LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1836
Mailing Address - Country:US
Mailing Address - Phone:561-312-0432
Mailing Address - Fax:
Practice Address - Street 1:1607 E WINDMILL LN STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1910
Practice Address - Country:US
Practice Address - Phone:702-757-8720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health