Basic Information
Provider Information | |||||||||
NPI: | 1982177317 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARVEY | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | CAMPBELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4850 SQUAW CREEK RD | ||||||||
Address2: |   | ||||||||
City: | CASPER | ||||||||
State: | WY | ||||||||
PostalCode: | 826044257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4065816677 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12020 PACIFIC ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681543507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002599897 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2019 | ||||||||
LastUpdateDate: | 01/09/2019 | ||||||||
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 | 225X00000X | 19445 | CA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | OTP-OT-LIC-3921 | MT | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | OT-2017 | ID | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0105919854111 | 01 | MT | DRIVERS LICENSE | OTHER |