Provider Demographics
NPI:1801300488
Name:RICHARD, LAURISA (ATC)
Entity type:Individual
Prefix:
First Name:LAURISA
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 STEPHEN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-2022
Mailing Address - Country:US
Mailing Address - Phone:260-388-3408
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9401
Practice Address - Country:US
Practice Address - Phone:616-331-9385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010017602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer