Healthcare Provider Details

I. General information

NPI: 1972564599
Provider Name (Legal Business Name): KRISTIN ACKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 S CEDAR ST BLDG 2
LANSING MI
48911-3800
US

IV. Provider business mailing address

812 E JOLLY RD
LANSING MI
48910-6818
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8302
  • Fax:
Mailing address:
  • Phone: 517-346-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801065873
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: