Basic Information
| Provider Information | |||||||||
| NPI: | 1689119281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 LINCOLN AVE | ||||||||
| Address2: | APT 3 N | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605461938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532285365 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1023 BURLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERN SPRINGS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605581516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087455277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2017 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.