Provider Demographics
NPI:1164995403
Name:SQUIRES, LAURIE ANN (COTA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:ANN
Other - Last Name:SQUIRES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:1868 S VILLA CT
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1835
Mailing Address - Country:US
Mailing Address - Phone:616-550-9704
Mailing Address - Fax:
Practice Address - Street 1:2394 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9402
Practice Address - Country:US
Practice Address - Phone:989-671-3502
Practice Address - Fax:989-671-3502
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2701129799224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06011946Medicaid