Provider Demographics
NPI:1780681882
Name:STICKLER, LAURIE GRACE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:GRACE
Last Name:STICKLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 GRAND RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4565 WILSON AVE SW
Practice Address - Street 2:STE 5A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2371
Practice Address - Country:US
Practice Address - Phone:616-975-9078
Practice Address - Fax:616-975-9248
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20-0223019OtherTAX ID
MILS010775OtherLICENSE NUMBER
MI650D114420OtherBLUE CROSS BLUE SHIELD
MIP35364FOtherBLUE CARE NETWORK