Provider Demographics
NPI:1285946764
Name:BRANDT, LAURA A (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:BRANDT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13787 GRINDLE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9324
Mailing Address - Country:US
Mailing Address - Phone:616-987-3412
Mailing Address - Fax:616-897-7054
Practice Address - Street 1:11650 DOWNES ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-9489
Practice Address - Country:US
Practice Address - Phone:616-289-7784
Practice Address - Fax:616-897-7054
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012591103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist