Provider Demographics
NPI:1598914483
Name:LAUBENTHAL, KEYRON NICK (CO, PT)
Entity Type:Individual
Prefix:
First Name:KEYRON
Middle Name:NICK
Last Name:LAUBENTHAL
Suffix:
Gender:F
Credentials:CO, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 TOWNCREST DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-6631
Mailing Address - Country:US
Mailing Address - Phone:319-354-2429
Mailing Address - Fax:319-354-6100
Practice Address - Street 1:540 E JEFFERSON ST
Practice Address - Street 2:SUITE 302
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2477
Practice Address - Country:US
Practice Address - Phone:319-339-3611
Practice Address - Fax:319-339-3878
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00301222Z00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665463Medicaid
IA0665463Medicaid