Healthcare Provider Details

I. General information

NPI: 1336271865
Provider Name (Legal Business Name): THEODORE KARL KASPER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12211 MENTZ DR
BRUCE MI
48065-4436
US

IV. Provider business mailing address

12211 MENTZ DR
BRUCE MI
48065-4436
US

V. Phone/Fax

Practice location:
  • Phone: 586-255-2259
  • Fax:
Mailing address:
  • Phone: 586-255-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801059521
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: