Provider Demographics
NPI:1649358953
Name:HAGAN, LAURA B (OT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:B
Last Name:HAGAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BRICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:10020 PROFESSIONAL CENTER DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMBURG
Practice Address - State:MI
Practice Address - Zip Code:48139
Practice Address - Country:US
Practice Address - Phone:810-231-6904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2485225X00000X
MI5201004245225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2485OtherLICENSE
MIP01437456OtherRR MEDICARE
MIP01437456OtherRR MEDICARE