=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699894394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE FLOREN BENNETT AUD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 03/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2660 44TH ST SW STE 400
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-6836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-530-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3535 PARK ST STE 106
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-374-5702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 1601000028
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 1601000028
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------