Healthcare Provider Details

I. General information

NPI: 1578160743
Provider Name (Legal Business Name): LAUREN KUDIRKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 COLLINGWOOD ST STE 226
DETROIT MI
48206-1500
US

IV. Provider business mailing address

1700 HICKORY VALLEY RD
MILFORD MI
48380-4273
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-4601
  • Fax:
Mailing address:
  • Phone: 248-770-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101009183
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: