Healthcare Provider Details

I. General information

NPI: 1356749386
Provider Name (Legal Business Name): KAITLIN HERZOG T.L.L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 E MAIN ST
NORTHVILLE MI
48167-2676
US

IV. Provider business mailing address

186 E MAIN ST
NORTHVILLE MI
48167-2676
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015644
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: