Provider Demographics
NPI:1417691510
Name:MACKIMMIE, LAURA LYNNE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:MACKIMMIE
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 1:8501 WERKNER RD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-9127
Mailing Address - Country:US
Mailing Address - Phone:734-645-5201
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE STE 205
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4200
Practice Address - Country:US
Practice Address - Phone:734-913-1093
Practice Address - Fax:734-369-2683
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004082103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical