Provider Demographics
NPI:1619239548
Name:LAURENCELLE, MATTHEW JON (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JON
Last Name:LAURENCELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12851 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-8506
Mailing Address - Country:US
Mailing Address - Phone:810-227-1211
Mailing Address - Fax:
Practice Address - Street 1:12851 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-8506
Practice Address - Country:US
Practice Address - Phone:810-227-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011010162084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry