Provider Demographics
NPI:1548890106
Name:LAWRENCE, MARY DAWN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DAWN
Last Name:LAWRENCE
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 1:1420 RENAISSANCE DR APT E105
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7065
Mailing Address - Country:US
Mailing Address - Phone:661-607-8588
Mailing Address - Fax:
Practice Address - Street 1:1233 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6133
Practice Address - Country:US
Practice Address - Phone:720-772-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician