Healthcare Provider Details

I. General information

NPI: 1003302878
Provider Name (Legal Business Name): LAUREN LUSK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 BYRD AVE
RICHMOND VA
23230-3033
US

IV. Provider business mailing address

15706 DRAYCOT DR
MIDLOTHIAN VA
23112-5515
US

V. Phone/Fax

Practice location:
  • Phone: 804-592-6311
  • Fax:
Mailing address:
  • Phone: 804-317-5576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701008282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: