Provider Demographics
NPI:1144596529
Name:CHARBONEAU, LAUREN NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:CHARBONEAU
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 1:6441 ORCHID DR
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9333
Mailing Address - Country:US
Mailing Address - Phone:616-204-0521
Mailing Address - Fax:
Practice Address - Street 1:6441 ORCHID DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9333
Practice Address - Country:US
Practice Address - Phone:616-204-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002955225200000X
TX2087963225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant