Provider Demographics
NPI:1710378237
Name:ERBENTRAUT, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ERBENTRAUT
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 1:3410 18TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1402
Mailing Address - Country:US
Mailing Address - Phone:262-671-1759
Mailing Address - Fax:262-347-3603
Practice Address - Street 1:3410 18TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1402
Practice Address - Country:US
Practice Address - Phone:262-671-1759
Practice Address - Fax:262-347-3603
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI-560790172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver