MEDICARE: MS. LAURA MARTHA GRIFFIN MS, ATR-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist	54-036	WI

General Provider Information

NPI Number	:	1417173568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA MARTHA GRIFFIN MS, ATR-BC

Provider Business Mailing Address
First Line	:	3908 N 46TH ST
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53083-2546
Country	:	US
Telephone Number	:	920-458-1675
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 SAINT CLAIR AVE
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53081-3233
Country	:	US
Telephone Number	:	920-458-8261
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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