Basic Information
Provider Information | |||||||||
NPI: | 1508176322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRAEMER | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | GROVES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GROVES | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: | ANGELA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LICSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 1ST ST NE FL 9 | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200027953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024425885 | ||||||||
FaxNumber: | 2026982466 | ||||||||
Practice Location | |||||||||
Address1: | 1200 1ST ST NE FL 9 | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200027953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024425885 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2010 | ||||||||
LastUpdateDate: | 11/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC50078527 | DC | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X | LC50078527 | DC | N |   | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
ID | Type | State | Issuer | Description | 536001131 | 05 | DC |   | MEDICAID |