Provider Demographics
NPI:1275397242
Name:ETTUS, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ETTUS
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 1:1605 AMBERGATE DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6751
Mailing Address - Country:US
Mailing Address - Phone:954-415-9904
Mailing Address - Fax:
Practice Address - Street 1:402 LANE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5456
Practice Address - Country:US
Practice Address - Phone:704-233-3428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20470235Z00000X
NC30004252235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist