Healthcare Provider Details

I. General information

NPI: 1699875369
Provider Name (Legal Business Name): KATHLEEN A TAIT MA, LPC, CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 NORTHWIND DR STE 108
EAST LANSING MI
48823-5034
US

IV. Provider business mailing address

1031 E SAGINAW ST
LANSING MI
48906-5519
US

V. Phone/Fax

Practice location:
  • Phone: 517-336-4335
  • Fax: 517-336-0101
Mailing address:
  • Phone: 517-487-9642
  • Fax: 517-487-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401002812
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: