Healthcare Provider Details

I. General information

NPI: 1134502651
Provider Name (Legal Business Name): CHRISTINE MARIE LAURENT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 FOURIER DR SUITE #100
MADISON WI
53717-1969
US

IV. Provider business mailing address

1210 FOURIER DR SUITE #100
MADISON WI
53717-1969
US

V. Phone/Fax

Practice location:
  • Phone: 608-662-9327
  • Fax: 608-662-9041
Mailing address:
  • Phone: 608-662-9327
  • Fax: 608-662-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number95-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: