Provider Demographics
NPI:1982177317
Name:HARVEY, LAUREN CAMPBELL
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:CAMPBELL
Last Name:HARVEY
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 1:4850 SQUAW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4257
Mailing Address - Country:US
Mailing Address - Phone:406-581-6677
Mailing Address - Fax:
Practice Address - Street 1:12020 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-3507
Practice Address - Country:US
Practice Address - Phone:800-259-9897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19445225X00000X
MTOTP-OT-LIC-3921225X00000X
IDOT-2017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0105919854111OtherDRIVERS LICENSE