Healthcare Provider Details

I. General information

NPI: 1366088239
Provider Name (Legal Business Name): KARLI ICEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 BARCLAY CIR STE 400
ROCHESTER HILLS MI
48307-5812
US

IV. Provider business mailing address

45925 SPRING LN APT 103
SHELBY TOWNSHIP MI
48317-4857
US

V. Phone/Fax

Practice location:
  • Phone: 313-626-0938
  • Fax:
Mailing address:
  • Phone: 248-860-1908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401017146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: