Provider Demographics
NPI:1720550403
Name:PATCHEL, LAURA JANE (OTL)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:PATCHEL
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1140
Mailing Address - Country:US
Mailing Address - Phone:810-364-4332
Mailing Address - Fax:
Practice Address - Street 1:1411 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5480
Practice Address - Country:US
Practice Address - Phone:810-488-8380
Practice Address - Fax:810-985-5543
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001504225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609989805Medicaid
MI1306227764Medicaid