=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295454700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ELISE PETERSON HIGGINS MS, BC-DMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2022
-----------------------------------------------------
Last Update Date | 08/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4906 SAINT ELMO AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37409-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-653-4478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4906 SAINT ELMO AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37409-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-653-4478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225600000X
-----------------------------------------------------
Taxonomy Name | Dance Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------