Healthcare Provider Details

I. General information

NPI: 1821480104
Provider Name (Legal Business Name): LAURA DANIELLE MAMMEN LPC, LMFT, NCC, ACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 LEONARD ST NE
GRAND RAPIDS MI
49503-1138
US

IV. Provider business mailing address

805 LEONARD ST NE
GRAND RAPIDS MI
49503-1138
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-4617
  • Fax: 616-361-4141
Mailing address:
  • Phone: 616-774-4617
  • Fax: 616-361-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401007999
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006214
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: