=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821480104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA DANIELLE MAMMEN LPC, LMFT, NCC, ACS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 LEONARD ST NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-774-4617
-----------------------------------------------------
Fax | 616-361-4141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 LEONARD ST NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-774-4617
-----------------------------------------------------
Fax | 616-361-4141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401007999
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4101006214
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------