Provider Demographics
NPI:1518414788
Name:ROTHWELL, LAURA KIM (LMT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KIM
Last Name:ROTHWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 W CENTRE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5396
Mailing Address - Country:US
Mailing Address - Phone:269-321-2133
Mailing Address - Fax:
Practice Address - Street 1:1601 W CENTRE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5396
Practice Address - Country:US
Practice Address - Phone:269-321-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006692225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist