Healthcare Provider Details

I. General information

NPI: 1942586086
Provider Name (Legal Business Name): T MICHAEL KNACK PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 TOWNE CTR STE 205
SAGINAW MI
48604-2841
US

IV. Provider business mailing address

11254 LAKE CIRCLE DR N
SAGINAW MI
48609-9454
US

V. Phone/Fax

Practice location:
  • Phone: 989-921-5715
  • Fax: 989-921-5960
Mailing address:
  • Phone: 989-981-0731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301001789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: