Provider Demographics
NPI:1154489425
Name:DETERT, LAURA LEANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEANNE
Last Name:DETERT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:WI
Mailing Address - Zip Code:54950-0485
Mailing Address - Country:US
Mailing Address - Phone:715-754-2555
Mailing Address - Fax:715-754-2556
Practice Address - Street 1:1101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:WI
Practice Address - Zip Code:54950-9182
Practice Address - Country:US
Practice Address - Phone:715-754-2555
Practice Address - Fax:715-754-2556
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2895-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38984900Medicaid
WI38866500Medicaid
WI38866500Medicaid
WI38984900Medicaid