Provider Demographics
NPI:1881092492
Name:HIGGINBOTHAM, LAURIE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 TAHITI LN
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6930
Mailing Address - Country:US
Mailing Address - Phone:510-301-4027
Mailing Address - Fax:510-550-7009
Practice Address - Street 1:512 WESTLINE DR STE 204
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-7605
Practice Address - Country:US
Practice Address - Phone:510-301-4027
Practice Address - Fax:510-550-7009
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11971225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist