Provider Demographics
NPI:1649766460
Name:WILLIS, LAUREN BROOKE (LCADC)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:BROOKE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1049
Mailing Address - Country:US
Mailing Address - Phone:267-265-6357
Mailing Address - Fax:
Practice Address - Street 1:537 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1603
Practice Address - Country:US
Practice Address - Phone:856-686-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00271900101YA0400X
NJ37AC00467900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37LC00271900OtherLCADC