Basic Information
| Provider Information | |||||||||
| NPI: | 1265528756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENDER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ROSEMARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEMARAY | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | ROSEMARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24575 HALLEY CRESCENT DR | ||||||||
| Address2: | |||||||||
| City: | GROSSE ILE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481381616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346762794 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33101 ANNAPOLIS ST STE B | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481842405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347210200 | ||||||||
| FaxNumber: | 7347212008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 4704110454 | MI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.