Healthcare Provider Details

I. General information

NPI: 1356067631
Provider Name (Legal Business Name): KALEIDOSCOPE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LONGWOOD DR SW STE C
HUNTSVILLE AL
35801-4511
US

IV. Provider business mailing address

113 LONGWOOD DR SW STE C
HUNTSVILLE AL
35801-4511
US

V. Phone/Fax

Practice location:
  • Phone: 256-886-9443
  • Fax:
Mailing address:
  • Phone: 256-886-9443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE HASE
Title or Position: OWNER
Credential: LICSW
Phone: 256-886-9443