Healthcare Provider Details

I. General information

NPI: 1265630586
Provider Name (Legal Business Name): KATHLEEN J. STAUGAENO MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

5388 FOREST RIDGE DR
CLARKSTON MI
48346-3479
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7701
  • Fax:
Mailing address:
  • Phone: 248-620-1168
  • Fax: 248-620-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013278
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: