Provider Demographics
NPI:1447773049
Name:DRLIK, LAURA JEAN (PT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:DRLIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAWN
Mailing Address - State:MI
Mailing Address - Zip Code:49637-9524
Mailing Address - Country:US
Mailing Address - Phone:989-859-5860
Mailing Address - Fax:
Practice Address - Street 1:9715 E CHERRY BEND RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7621
Practice Address - Country:US
Practice Address - Phone:231-421-5036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501005258OtherMICHIGAN DEPARTMENT OF COMMUNITY HEALTH (STATE LICENSE)