Basic Information
| Provider Information | |||||||||
| NPI: | 1851316509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILDOW | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., L.L.P., L.L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6770 DIXIE HWY. | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489222300 | ||||||||
| FaxNumber: | 2489222304 | ||||||||
| Practice Location | |||||||||
| Address1: | 6770 DIXIE HWY | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483462087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489222300 | ||||||||
| FaxNumber: | 2489222304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401005666 | MI | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC1900X | 6301009407 | MI | X | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.