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NPI Code Detail

MEDICARE: MRS. MARIA KANISZEWSKI

MEDICARE: MRS. MARIA KANISZEWSKI
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselorL1764585MI
2103TC2200XClinical Child & Adolescent PsychologistL1815378MI

General Provider Information

NPI Number : 1740599216
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MARIA KANISZEWSKI
Provider Business Mailing Address
First Line : 2715 S TOWNLINE RD
Second Line :
City : HOUGHTON LAKE
State : MI
Zip : 48629-9294
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2715 S TOWNLINE RD
Second Line :
City : HOUGHTON LAKE
State : MI
Zip : 48629-9294
Country : US
Telephone Number : 989-366-1118
Fax Number : 989-366-9420
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/01/2010
Last Update Date : 10/01/2010

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