Healthcare Provider Details

I. General information

NPI: 1700235843
Provider Name (Legal Business Name): MARK KAUFFMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 STEPHENSON HWY SUITE 210
TROY MI
48083-1152
US

IV. Provider business mailing address

1613 EDGEWOOD DR
ROYAL OAK MI
48067-1298
US

V. Phone/Fax

Practice location:
  • Phone: 248-585-3239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401015161
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401015161
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401015161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: