Healthcare Provider Details

I. General information

NPI: 1679080030
Provider Name (Legal Business Name): KRISTEN QUALLS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 BARCLAY CIR STE 105
ROCHESTER HILLS MI
48307-4575
US

IV. Provider business mailing address

1915 CASTLETON DR
TROY MI
48083-2613
US

V. Phone/Fax

Practice location:
  • Phone: 810-397-4861
  • Fax:
Mailing address:
  • Phone: 810-397-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011017
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006433
License Number StateMI

VIII. Authorized Official

Name: KRISTEN QUALLS
Title or Position: PRESIDENT
Credential: LPC, LMFT
Phone: 810-397-4861