Healthcare Provider Details

I. General information

NPI: 1619462512
Provider Name (Legal Business Name): LAUREN SHIPMAN MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 S DIVISION AVE.
GRAND RAPIDS MI
49507
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 616-247-3815
  • Fax: 616-245-0450
Mailing address:
  • Phone: 914-294-4050
  • Fax: 616-245-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201013673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: