Healthcare Provider Details

I. General information

NPI: 1912639428
Provider Name (Legal Business Name): LAURYN GENEVIEVE LELLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 S CICERO AVE STE F
OAK LAWN IL
60453-4098
US

IV. Provider business mailing address

7310 SMOKE RANCH RD STE S
LAS VEGAS NV
89128-0260
US

V. Phone/Fax

Practice location:
  • Phone: 708-232-8763
  • Fax: 708-232-8993
Mailing address:
  • Phone: 702-608-7290
  • Fax: 702-973-7373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI4460
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: