=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386736460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA A CLOUSE OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 N COUNTYLINE ST
-----------------------------------------------------
City | FOSTORIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44830-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-436-9764
-----------------------------------------------------
Fax | 419-436-9782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5980 E STATE ROUTE 18
-----------------------------------------------------
City | REPUBLIC
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44867-9309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-447-7203
-----------------------------------------------------
Fax | 419-447-5577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 05490
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------