Healthcare Provider Details

I. General information

NPI: 1295015295
Provider Name (Legal Business Name): LAUREN VANDERLOO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7908 NORTHWEST 23RD ST
BETHANY OK
73008
US

IV. Provider business mailing address

7908 NORTHWEST 23RD ST
BETHANY OK
73008
US

V. Phone/Fax

Practice location:
  • Phone: 405-440-1006
  • Fax: 405-440-1007
Mailing address:
  • Phone: 405-440-1006
  • Fax: 405-440-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: