MEDICARE: LITTLE HOUSE ON MACKINAW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1639831993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE HOUSE ON MACKINAW, LLC

Provider Business Mailing Address
First Line	:	6988 MACKINAW RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-9332
Country	:	US
Telephone Number	:	989-790-2005
Fax Number	:	989-790-2002

Provider Business Practice Location Address
First Line	:	6988 MACKINAW RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-9332
Country	:	US
Telephone Number	:	989-790-2005
Fax Number	:	989-790-2002

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DIANE KUKULIS
Credential	:	LMSW
Telephone Number	:	989-790-2005

Provider Enumeration Date	:	10/13/2021
Last Update Date	:	10/13/2021

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