MEDICARE: LAURA T WOODWORTH OTR

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	225X00000X	Occupational Therapist	5201000682	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5201000682	OTHER	MI	STATE OTRREGISTRATION NO

General Provider Information

NPI Number	:	1972503258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA T WOODWORTH OTR

Provider Business Mailing Address
First Line	:	2500 S HILL RD
Second Line	:
City	:	GLADSTONE
State	:	MI
Zip	:	49837-2310
Country	:	US
Telephone Number	:	906-630-1293
Fax Number	:	906-428-2699

Provider Business Practice Location Address
First Line	:	2500 S HILL RD
Second Line	:
City	:	GLADSTONE
State	:	MI
Zip	:	49837-2310
Country	:	US
Telephone Number	:	906-630-1293
Fax Number	:	906-428-2699

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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