Provider Demographics
NPI:1083848725
Name:WHITTAKER, LAURA LYNN (BA, FAODP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LYNN
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:BA, FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4875 COPLIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2192
Mailing Address - Country:US
Mailing Address - Phone:313-822-1148
Mailing Address - Fax:313-822-1157
Practice Address - Street 1:4875 COPLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2192
Practice Address - Country:US
Practice Address - Phone:313-822-1148
Practice Address - Fax:313-822-1157
Is Sole Proprietor?:No
Enumeration Date:2009-05-10
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator