Provider Demographics
NPI:1447857156
Name:THAYER, LAUREN ELIZABETH
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:THAYER
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 1:3257 CITY VIEW CT
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9013
Mailing Address - Country:US
Mailing Address - Phone:231-519-5606
Mailing Address - Fax:
Practice Address - Street 1:3809 LAKE EASTBROOK BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5931
Practice Address - Country:US
Practice Address - Phone:616-604-8492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI106S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health