Healthcare Provider Details

I. General information

NPI: 1548383755
Provider Name (Legal Business Name): LAURA ROSE MIKRUT MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 LAKE DR SE SUITE 1
GRAND RAPIDS MI
49506-1674
US

IV. Provider business mailing address

1250 SAFFRON LN SE #2B
GRAND RAPIDS MI
49508-7355
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7215
  • Fax:
Mailing address:
  • Phone: 616-459-7215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: