Provider Demographics
NPI:1366972788
Name:MAKI, LAURA RENEE (SAC-IT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:RENEE
Last Name:MAKI
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3206
Mailing Address - Country:US
Mailing Address - Phone:920-973-8585
Mailing Address - Fax:
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-264-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17782-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)