Provider Demographics
NPI:1427502814
Name:SUAREZ, LAUREN MACKENZIE (MED)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MACKENZIE
Last Name:SUAREZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:MACKENZIE
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:63 WHITMORE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5660
Mailing Address - Country:US
Mailing Address - Phone:508-930-0361
Mailing Address - Fax:
Practice Address - Street 1:63 WHITMORE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5660
Practice Address - Country:US
Practice Address - Phone:508-930-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA455680101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor