Healthcare Provider Details

I. General information

NPI: 1053045484
Provider Name (Legal Business Name): LAUREN WATTERS MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

IV. Provider business mailing address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

V. Phone/Fax

Practice location:
  • Phone: 855-607-8242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6403-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: