Provider Demographics
NPI:1023777216
Name:MACDONALD, LAURA ROBERTA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ROBERTA
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ROBERTA
Other - Last Name:BIBEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5797 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-4733
Mailing Address - Country:US
Mailing Address - Phone:810-531-2704
Mailing Address - Fax:
Practice Address - Street 1:1406 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5804
Practice Address - Country:US
Practice Address - Phone:810-531-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist