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General NPI Number Information
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NPI Number | 1366972788
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Entity Type | Individual
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Provider Name | LAURA RENEE MAKI SAC-IT
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Gender | Female
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Dates
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Enumeration Date | 06/18/2017
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Last Update Date | 06/18/2017
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Provider Practice Location Address
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Address Line | 2842 S BUSINESS DR
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City | SHEBOYGAN
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State | WI
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Zip | 53081-6518
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Country | US
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Telephone | 920-264-0390
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Fax |
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Provider Business Mailing Address
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Address Line | 925 N 12TH ST
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City | MANITOWOC
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State | WI
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Zip | 54220-3206
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Country | US
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Telephone | 920-973-8585
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 17782-130
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License Number State | WI
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