Healthcare Provider Details

I. General information

NPI: 1154855385
Provider Name (Legal Business Name): KATHLEEN CONZELMANN LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 N STATE ST
CARO MI
48723-1543
US

IV. Provider business mailing address

443 N STATE ST
CARO MI
48723-1539
US

V. Phone/Fax

Practice location:
  • Phone: 989-673-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401009561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: