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General NPI Number Information
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NPI Number | 1902499767
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Entity Type | Organization
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Legal Business Name | MID-MITTEN PEDIATRIC PSYCHIATRY
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Dates
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Enumeration Date | 02/12/2021
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Last Update Date | 02/12/2021
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Provider Practice Location Address
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Address Line | 1660 HASLETT RD STE 1
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City | HASLETT
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State | MI
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Zip | 48840-8469
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Country | US
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Telephone | 517-347-8420
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Fax | 517-347-8420
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Provider Business Mailing Address
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Address Line | 1660 HASLETT RD STE 1
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City | HASLETT
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State | MI
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Zip | 48840-8469
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Country | US
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Telephone | 517-347-8420
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Fax | 517-347-8420
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | SAMANTHA FUGATE KENNEDY
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Credential | DO
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Telephone | 517-347-8420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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