Basic Information
| Provider Information | |||||||||
| NPI: | 1548383755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKRUT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 SAFFRON LN SE | ||||||||
| Address2: | #2B | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495087355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1331 LAKE DR SE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597215 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.