Healthcare Provider Details

I. General information

NPI: 1609042050
Provider Name (Legal Business Name): AMY MOON KUDLINSKI LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD # CF203
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1726 HOWARD ST
DETROIT MI
48216-1921
US

V. Phone/Fax

Practice location:
  • Phone: 313-433-2715
  • Fax:
Mailing address:
  • Phone: 313-832-3300
  • Fax: 313-832-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801082967
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: