Provider Demographics
NPI:1770845174
Name:PROUTY, LAURA M (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:PROUTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:920-430-4747
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400159883Medicare Oscar/Certification
WIK400265338Medicare Oscar/Certification
WIK400159877Medicare Oscar/Certification