Provider Demographics
NPI:1164633020
Name:MCDONNELL, LAURA DENISE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DENISE
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 PLAYER DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3372
Mailing Address - Country:US
Mailing Address - Phone:248-879-3706
Mailing Address - Fax:
Practice Address - Street 1:27450 SCHOENHERR RD
Practice Address - Street 2:100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6683
Practice Address - Country:US
Practice Address - Phone:586-582-7825
Practice Address - Fax:586-582-7826
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001089225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171931Medicaid
MI5171931Medicaid