Provider Demographics
NPI:1184738676
Name:FADELL, LAURA W (LLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:W
Last Name:FADELL
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3838
Mailing Address - Country:US
Mailing Address - Phone:810-984-4202
Mailing Address - Fax:
Practice Address - Street 1:520 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3838
Practice Address - Country:US
Practice Address - Phone:810-984-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012038103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical