Healthcare Provider Details

I. General information

NPI: 1013851088
Provider Name (Legal Business Name): KANIAH IESHA MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 MILLER RD
FLINT MI
48507-1267
US

IV. Provider business mailing address

3530 RUE FORET APT 36
FLINT MI
48532-2837
US

V. Phone/Fax

Practice location:
  • Phone: 248-549-4339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: