Healthcare Provider Details

I. General information

NPI: 1174032478
Provider Name (Legal Business Name): MARY KATHRYN AUSICH RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 S 12TH ST STE 200
PORTAGE MI
49024-3831
US

IV. Provider business mailing address

601 JOHN STREET BOX 39
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-8585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1024516
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: