Basic Information
| Provider Information | |||||||||
| NPI: | 1417691510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKIMMIE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8501 WERKNER RD | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481189127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346455201 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 WASHTENAW AVE STE 205 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481044200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349131093 | ||||||||
| FaxNumber: | 7343692683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2022 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6361004082 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.