MEDICARE: SHELBY LAURA RAYMOND

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	225800000X	Recreation Therapist	86207	MI

General Provider Information

NPI Number	:	1952047847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY LAURA RAYMOND

Provider Business Mailing Address
First Line	:	4249 E HERRICK RD
Second Line	:
City	:	CLARE
State	:	MI
Zip	:	48617-9325
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 N MAIN ST
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-5102
Country	:	US
Telephone Number	:	231-295-1196
Fax Number	:

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

Provider Enumeration Date	:	05/12/2022
Last Update Date	:	10/01/2024

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