Healthcare Provider Details

I. General information

NPI: 1922590835
Provider Name (Legal Business Name): LAUREN KULBERTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33466 GARFIELD RD
FRASER MI
48026-1892
US

IV. Provider business mailing address

33466 GARFIELD RD
FRASER MI
48026-1850
US

V. Phone/Fax

Practice location:
  • Phone: 586-429-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number978755
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: