Basic Information
| Provider Information | |||||||||
| NPI: | 1588610653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAUSBECK-MILLER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | MARY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPARTMENT 272801 | ||||||||
| Address2: | PO BOX 67000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 TENEYCK ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177871468 | ||||||||
| FaxNumber: | 5177870613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 3501003075 | MI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 4699819 | 05 | MI | MEDICAID |