Basic Information
| Provider Information | |||||||||
| NPI: | 1467999714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | LAUREN | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15023 21 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483155024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862869644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2221 LIVERNOIS RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485540360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-15-05273 | MI | N | 103K00000X | 7402000085 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.