Healthcare Provider Details

I. General information

NPI: 1992997837
Provider Name (Legal Business Name): KATHLEEN MARIE MICHAUD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 W STATE ST STE A
GARDEN CITY ID
83703-3085
US

IV. Provider business mailing address

PO BOX 140544
GARDEN CITY ID
83714-0544
US

V. Phone/Fax

Practice location:
  • Phone: 208-985-3340
  • Fax: 208-629-1358
Mailing address:
  • Phone: 208-985-3340
  • Fax: 208-629-1358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY202738
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: