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General NPI Number Information
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NPI Number | 1669961363
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Entity Type | Individual
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Provider Name | HANNAH KINGKITTISACK LBA, TLLP
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Gender | Female
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Dates
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Enumeration Date | 05/08/2018
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 16500 TIREMAN ST
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City | DETROIT
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State | MI
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Zip | 48228-3629
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Country | US
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Telephone | 313-451-1390
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Fax |
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Provider Business Mailing Address
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Address Line | 2675 FINI DR
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City | MILFORD
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State | MI
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Zip | 48380-3960
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Country | US
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Telephone | 810-599-0396
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 6362010066
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License Number State | MI
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