Provider Demographics
NPI:1407201411
Name:MITCHELL, LAURA (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15771 PARK LAKE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-9434
Mailing Address - Country:US
Mailing Address - Phone:517-927-9765
Mailing Address - Fax:
Practice Address - Street 1:250 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2740
Practice Address - Country:US
Practice Address - Phone:517-337-3080
Practice Address - Fax:517-337-3082
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM036023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist