Provider Demographics
NPI:1013389907
Name:MICHAEL, LAURA (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5843 STATE ROUTE 500
Mailing Address - Street 2:
Mailing Address - City:PAYNE
Mailing Address - State:OH
Mailing Address - Zip Code:45880-9408
Mailing Address - Country:US
Mailing Address - Phone:260-385-4234
Mailing Address - Fax:
Practice Address - Street 1:5843 STATE ROUTE 500
Practice Address - Street 2:
Practice Address - City:PAYNE
Practice Address - State:OH
Practice Address - Zip Code:45880-9408
Practice Address - Country:US
Practice Address - Phone:260-385-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001999A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility