Healthcare Provider Details

I. General information

NPI: 1639952435
Provider Name (Legal Business Name): MICHAEL MCKIDDY MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 E SOUTH BLVD STE 250
TROY MI
48085-1400
US

IV. Provider business mailing address

990 E SOUTH BLVD STE 250
TROY MI
48085-1400
US

V. Phone/Fax

Practice location:
  • Phone: 947-222-5429
  • Fax:
Mailing address:
  • Phone: 947-222-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401223662
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: