Provider Demographics
NPI:1902396146
Name:HERBERT, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:HERBERT
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 1:4897 MILLER TRUNK HWY STE 228
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1936
Mailing Address - Country:US
Mailing Address - Phone:218-451-8337
Mailing Address - Fax:
Practice Address - Street 1:4897 MILLER TRUNK HWY STE 228
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1936
Practice Address - Country:US
Practice Address - Phone:218-451-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist