Provider Demographics
NPI:1548383755
Name:MIKRUT, LAURA ROSE (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ROSE
Last Name:MIKRUT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 SAFFRON LN SE
Mailing Address - Street 2:#2B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7355
Mailing Address - Country:US
Mailing Address - Phone:616-459-7215
Mailing Address - Fax:
Practice Address - Street 1:1331 LAKE DR SE
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:616-459-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional