Provider Demographics
NPI:1770713521
Name:PHILLIPS, LAUREN ELIZABETH (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:HEAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:90 AIR PARK DR
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7360
Mailing Address - Country:US
Mailing Address - Phone:631-255-5491
Mailing Address - Fax:
Practice Address - Street 1:90 AIR PARK DR
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7360
Practice Address - Country:US
Practice Address - Phone:631-255-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1268453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03631436Medicaid