Provider Demographics
NPI:1275962748
Name:WEBER, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WEBER
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 1:555 N BRADLEY HWY
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-1539
Mailing Address - Country:US
Mailing Address - Phone:989-734-2151
Mailing Address - Fax:989-734-4311
Practice Address - Street 1:555 N BRADLEY HWY
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1539
Practice Address - Country:US
Practice Address - Phone:989-734-2151
Practice Address - Fax:989-734-4311
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist