Provider Demographics
NPI:1164764171
Name:WESTBROOK, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WESTBROOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 COMMERCIAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456
Mailing Address - Country:US
Mailing Address - Phone:843-314-5434
Mailing Address - Fax:888-510-9156
Practice Address - Street 1:3851 COMMERCIAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-2945
Practice Address - Country:US
Practice Address - Phone:843-314-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005870225XP0200X
SC4929225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3541Medicaid