Healthcare Provider Details

I. General information

NPI: 1093525933
Provider Name (Legal Business Name): KRYSTA KAYE DUFFANY CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRYSTA KAYE KOZLOWSKI CTRS

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 LIVERNOIS BLDG E STE 162
TROY MI
48083
US

IV. Provider business mailing address

2886 GRASS VALLEY DR
WHITE LAKE MI
48383-1804
US

V. Phone/Fax

Practice location:
  • Phone: 313-999-1866
  • Fax: 248-528-6667
Mailing address:
  • Phone: 313-999-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number49674
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: