Provider Demographics
NPI:1528302585
Name:CAVALLI, LAUREN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:CAVALLI
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3949 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8856
Mailing Address - Country:US
Mailing Address - Phone:989-702-2082
Mailing Address - Fax:
Practice Address - Street 1:600 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1354
Practice Address - Country:US
Practice Address - Phone:989-702-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
MI1-12-12347103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-12-12347OtherBCBA