Healthcare Provider Details

I. General information

NPI: 1811426125
Provider Name (Legal Business Name): LAUREN L BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16405 SAND CANYON AVE STE 220
IRVINE CA
92618-3787
US

IV. Provider business mailing address

32 FUCHSIA
LAKE FOREST CA
92630-1431
US

V. Phone/Fax

Practice location:
  • Phone: 949-336-8633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY31041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: