Provider Demographics
NPI:1407155534
Name:REA, LAURALEE (MSW)
Entity Type:Individual
Prefix:
First Name:LAURALEE
Middle Name:
Last Name:REA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 BALDWIN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1431
Mailing Address - Country:US
Mailing Address - Phone:616-262-9466
Mailing Address - Fax:
Practice Address - Street 1:9809 CHERRY VALLEY AVE SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9592
Practice Address - Country:US
Practice Address - Phone:616-262-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801089086104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI211715928Medicaid
MI211715928Medicaid