Healthcare Provider Details

I. General information

NPI: 1598349250
Provider Name (Legal Business Name): MARY KAY HAINES RDH, BCTN, FDN-P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 PARK ISLAND DR
LAKE ORION MI
48362-2762
US

IV. Provider business mailing address

224 PARK ISLAND DR
LAKE ORION MI
48362-2762
US

V. Phone/Fax

Practice location:
  • Phone: 248-722-2412
  • Fax:
Mailing address:
  • Phone: 248-722-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: