Provider Demographics
NPI:1750860540
Name:COPPERSMITH, LAURA E (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:COPPERSMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-392-2172
Mailing Address - Fax:616-392-1726
Practice Address - Street 1:286 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-392-2172
Practice Address - Fax:616-392-1726
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005041225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant