Healthcare Provider Details

I. General information

NPI: 1427599885
Provider Name (Legal Business Name): KATHLEEN MICHAUD PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2498 N STOKESBERRY PL SUITE 140
MERIDIAN ID
83646-5150
US

IV. Provider business mailing address

2498 N STOKESBERRY PL SUITE 140
MERIDIAN ID
83646-5150
US

V. Phone/Fax

Practice location:
  • Phone: 208-971-5806
  • Fax: 208-629-1358
Mailing address:
  • Phone: 208-971-5806
  • 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: DR. KATHLEEN M MICHAUD
Title or Position: CLINCIAL PSYCOLOGIIST, SOLE MBR
Credential: PHD
Phone: 208-971-5806