Healthcare Provider Details

I. General information

NPI: 1497275713
Provider Name (Legal Business Name): KAYLA MOCKRIDGE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E GRAND RIVER AVE STE A
BRIGHTON MI
48116-2474
US

IV. Provider business mailing address

9551 OAKBROOKE LN APT 12
HOWELL MI
48843-6338
US

V. Phone/Fax

Practice location:
  • Phone: 989-890-8228
  • Fax:
Mailing address:
  • Phone: 989-890-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114459
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: