Provider Demographics
NPI:1487859278
Name:ANDERSON, LAURIE LYNN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:CRABB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1731 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5046
Mailing Address - Country:US
Mailing Address - Phone:920-676-4916
Mailing Address - Fax:
Practice Address - Street 1:2801 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2878
Practice Address - Country:US
Practice Address - Phone:920-337-1122
Practice Address - Fax:920-337-1126
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1243-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41810300Medicaid