Provider Demographics
NPI:1972503258
Name:WOODWORTH, LAURA T (OTR)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:T
Last Name:WOODWORTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-2310
Mailing Address - Country:US
Mailing Address - Phone:906-630-1293
Mailing Address - Fax:906-428-2699
Practice Address - Street 1:2500 S HILL RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-2310
Practice Address - Country:US
Practice Address - Phone:906-630-1293
Practice Address - Fax:906-428-2699
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201000682OtherSTATE OTRREGISTRATION NO
OM99810Medicare ID - Type Unspecified
PO5199Medicare UPIN