Provider Demographics
NPI:1467825489
Name:SMITH, LAUREN ELIZABETH (AT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 LAFAYETTE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1660
Mailing Address - Country:US
Mailing Address - Phone:269-760-5085
Mailing Address - Fax:
Practice Address - Street 1:610 LAFAYETTE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1660
Practice Address - Country:US
Practice Address - Phone:269-760-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010011242255A2300X
MI5501017854208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer