Healthcare Provider Details

I. General information

NPI: 1487054441
Provider Name (Legal Business Name): KYRSTINA HUDSON MARIOUW PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYRSTINA HUDSON

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 W BIG BEAVER RD STE 150
TROY MI
48084-2931
US

IV. Provider business mailing address

1335 SHEEHAN AVE
ANN ARBOR MI
48104-3837
US

V. Phone/Fax

Practice location:
  • Phone: 248-792-6527
  • Fax: 248-792-9106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301018301
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: