Provider Demographics
NPI:1528671138
Name:LAUVSTAD, BLAIR
Entity type:Individual
Prefix:MS
First Name:BLAIR
Middle Name:
Last Name:LAUVSTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 BRADFORD CIR
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-5052
Mailing Address - Country:US
Mailing Address - Phone:816-853-6477
Mailing Address - Fax:
Practice Address - Street 1:13905 TECHNOLOGY DR # A1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1054
Practice Address - Country:US
Practice Address - Phone:405-389-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-20-132444106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician