Provider Demographics
NPI:1588247126
Name:VAN WIE, LAUREN (MS BCBA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 EDDY RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8186
Mailing Address - Country:US
Mailing Address - Phone:848-525-3517
Mailing Address - Fax:
Practice Address - Street 1:1706 MILL POND RD STE B
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29527-4745
Practice Address - Country:US
Practice Address - Phone:843-488-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-21-47983103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst