Basic Information
Provider Information | |||||||||
NPI: | 1114423852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROUWERS | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | FAITH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCKEE | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: | FAITH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, BCBA | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462686135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8553240885 | ||||||||
FaxNumber: | 3175208200 | ||||||||
Practice Location | |||||||||
Address1: | 251 W 84TH DR | ||||||||
Address2: |   | ||||||||
City: | MERRILLVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 464106243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2192053463 | ||||||||
FaxNumber: | 3175208200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2018 | ||||||||
LastUpdateDate: | 07/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-30015 | IN | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 300060627 | 05 | IN |   | MEDICAID |