Provider Demographics
NPI:1528561388
Name:PACKARD, LAUREL MARGARET
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:MARGARET
Last Name:PACKARD
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 1:6240 RYAN VALLEY DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-8001
Mailing Address - Country:US
Mailing Address - Phone:734-646-1985
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:734-646-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006328225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation