Healthcare Provider Details

I. General information

NPI: 1639831993
Provider Name (Legal Business Name): LITTLE HOUSE ON MACKINAW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6988 MACKINAW RD
BAY CITY MI
48706-9332
US

IV. Provider business mailing address

6988 MACKINAW RD
BAY CITY MI
48706-9332
US

V. Phone/Fax

Practice location:
  • Phone: 989-790-2005
  • Fax: 989-790-2002
Mailing address:
  • Phone: 989-790-2005
  • Fax: 989-790-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DIANE KUKULIS
Title or Position: SOLE MEMBER
Credential: LMSW
Phone: 989-790-2005