Provider Demographics
NPI:1073083259
Name:AMENTA, LAURA BETH (MS, OTR)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:BETH
Last Name:AMENTA
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:BETH
Other - Last Name:AMENTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR
Mailing Address - Street 1:4234 GREENBRIER CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2228
Mailing Address - Country:US
Mailing Address - Phone:646-229-6348
Mailing Address - Fax:
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-226-2945
Practice Address - Fax:616-940-8151
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006983225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist