Healthcare Provider Details

I. General information

NPI: 1982154852
Provider Name (Legal Business Name): CRISCIA NICOLE KASEM LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 E COLDWATER RD
FLINT MI
48505-1501
US

IV. Provider business mailing address

1057 E COLDWATER RD
FLINT MI
48505-1501
US

V. Phone/Fax

Practice location:
  • Phone: 810-257-3705
  • Fax:
Mailing address:
  • Phone: 810-257-3705
  • Fax: 810-257-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301016246
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007122
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: