Provider Demographics
NPI:1114497856
Name:WITSAMAN, LAUREN (OTR)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WITSAMAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 YORK VIEW CT NW
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8926
Mailing Address - Country:US
Mailing Address - Phone:616-901-0073
Mailing Address - Fax:
Practice Address - Street 1:5101 BRITTANY DR S STE 16
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33715-1565
Practice Address - Country:US
Practice Address - Phone:727-308-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI084581225X00000X
FLOT19866225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist