Healthcare Provider Details

I. General information

NPI: 1528561388
Provider Name (Legal Business Name): LAUREL MARGARET PACKARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

6240 RYAN VALLEY DR NE
BELMONT MI
49306-8001
US

V. Phone/Fax

Practice location:
  • Phone: 734-646-1985
  • Fax:
Mailing address:
  • Phone: 734-646-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201006328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: