Provider Demographics
NPI:1104318518
Name:GAUDIN, LAUREL (COTA)
Entity type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:
Last Name:GAUDIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S 4TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2743
Mailing Address - Country:US
Mailing Address - Phone:269-240-7780
Mailing Address - Fax:
Practice Address - Street 1:1333 WELLS ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-1543
Practice Address - Country:US
Practice Address - Phone:269-240-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001655A224Z00000X
MI5202007304224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant