Healthcare Provider Details

I. General information

NPI: 1831638659
Provider Name (Legal Business Name): KATHLEEN CHAMISA MACKENZIE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E WASHINGTON ST STE 401
ANN ARBOR MI
48104-2017
US

IV. Provider business mailing address

202 E WASHINGTON ST STE 401
ANN ARBOR MI
48104-2017
US

V. Phone/Fax

Practice location:
  • Phone: 734-926-8162
  • Fax:
Mailing address:
  • Phone: 734-926-8162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6801097665
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: