Provider Demographics
NPI:1649758178
Name:LAUBENTHAL, BRIAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LAUBENTHAL
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:GLANDORF
Mailing Address - State:OH
Mailing Address - Zip Code:45848-0039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-783-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006544224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant