Provider Demographics
NPI:1912556879
Name:DESJARDIN, LAUREN (BCBA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:DESJARDIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 RANDALL ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1921
Mailing Address - Country:US
Mailing Address - Phone:850-855-9102
Mailing Address - Fax:
Practice Address - Street 1:103 RICKEY AVE UNIT C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2520
Practice Address - Country:US
Practice Address - Phone:850-376-5624
Practice Address - Fax:850-937-7381
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-43324103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst