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General NPI Number Information
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NPI Number | 1679336077
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Entity Type | Organization
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Legal Business Name | KINTSUGI MENTAL HEALTH LLC
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Dates
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Enumeration Date | 01/30/2024
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Last Update Date | 03/06/2024
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Provider Practice Location Address
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Address Line | 119 MARTIN LUTHER KING JR BLVD STE LL-20
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City | MADISON
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State | WI
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Zip | 53703-3355
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Country | US
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Telephone | 608-291-3586
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Fax |
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Provider Business Mailing Address
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Address Line | 5902 TOLMAN TER
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City | MADISON
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State | WI
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Zip | 53711-3360
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Country | US
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Telephone | 781-698-9171
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Fax |
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Authorized Official
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Title or Position | OWNER/LICENSED PSYCHOLOGIST
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Name | JAIME LAM
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Credential | PHD, LP
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Telephone | 781-698-9171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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