Provider Demographics
NPI:1073859831
Name:LAU, THOMAS RAE
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAE
Last Name:LAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 COLUMBIA BLVD
Mailing Address - Street 2:SUITE B106
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7865
Mailing Address - Country:US
Mailing Address - Phone:321-267-9746
Mailing Address - Fax:321-267-9745
Practice Address - Street 1:3055 COLUMBIA BLVD
Practice Address - Street 2:SUITE B106
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7865
Practice Address - Country:US
Practice Address - Phone:321-267-9746
Practice Address - Fax:321-267-9745
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLHAS002796237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist