Healthcare Provider Details

I. General information

NPI: 1962045708
Provider Name (Legal Business Name): KENZIE M TIMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 STEPHENSON HWY STE 210
TROY MI
48083-1151
US

IV. Provider business mailing address

850 STEPHENSON HWY STE 210
TROY MI
48083-1151
US

V. Phone/Fax

Practice location:
  • Phone: 248-585-3239
  • Fax: 248-585-3239
Mailing address:
  • Phone: 248-585-3239
  • Fax: 248-616-9759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401017477
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: