Basic Information
| Provider Information | |||||||||
| NPI: | 1073805818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANSOU | ||||||||
| FirstName: | MARCIE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 FORT ST | ||||||||
| Address2: | #807 | ||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481461889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482122304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401010715 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.