Healthcare Provider Details

I. General information

NPI: 1578820643
Provider Name (Legal Business Name): LAUREN JAYASURIYA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 E ELLSWORTH RD
ANN ARBOR MI
48108-2552
US

IV. Provider business mailing address

555 TOWNER ST
YPSILANTI MI
48198-5752
US

V. Phone/Fax

Practice location:
  • Phone: 734-544-3400
  • Fax: 734-971-2487
Mailing address:
  • Phone: 734-544-3000
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089977
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number6801089977
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number6801089977
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: