Provider Demographics
NPI:1760966964
Name:THOMAS, LAURA ELIZABETH
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:THOMAS
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 1:59617 SILVERGRASS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5722 METRO WAY SW STE B
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9524
Practice Address - Country:US
Practice Address - Phone:616-252-6034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00000000000000000000OtherBCBS