Provider Demographics
NPI:1972144285
Name:DATTILO, LAUREN (PHD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:
Last Name:DATTILO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 DEERING AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4858
Mailing Address - Country:US
Mailing Address - Phone:207-220-1194
Mailing Address - Fax:
Practice Address - Street 1:257 DEERING AVE STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4858
Practice Address - Country:US
Practice Address - Phone:207-220-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS2003103T00000X, 103TC0700X
TN3577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist