Provider Demographics
NPI:1003779240
Name:VICK, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:VICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 PILLSBURY AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5517
Mailing Address - Country:US
Mailing Address - Phone:612-226-7659
Mailing Address - Fax:
Practice Address - Street 1:1250 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2533
Practice Address - Country:US
Practice Address - Phone:612-668-0254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist