MEDICARE: MRS. LAURIE MICHELE PEACE DI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist	200184031	KY

General Provider Information

NPI Number	:	1730688581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURIE MICHELE PEACE DI

Provider Business Mailing Address
First Line	:	5360 MILLSTONE CT UNIT 3E
Second Line	:
City	:	TAYLOR MILL
State	:	KY
Zip	:	41015-4511
Country	:	US
Telephone Number	:	859-907-9592
Fax Number	:

Provider Business Practice Location Address
First Line	:	5360 MILLSTONE CT UNIT 3E
Second Line	:
City	:	TAYLOR MILL
State	:	KY
Zip	:	41015-4511
Country	:	US
Telephone Number	:	859-907-9592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	02/12/2018

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