Basic Information
| Provider Information | |||||||||
| NPI: | 1427546274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAVER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WILLOW CREST CIR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390477064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7745711310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
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| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177244133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2018 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 285912 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.