Basic Information
| Provider Information | |||||||||
| NPI: | 1902974231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KRISTIN M MELOTIK PLC | ||||||||
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| OtherOrganizationName: | KRISTIN MARIE PERIARD MSW, LMSW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WEST MAIN ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483476110 | ||||||||
| FaxNumber: | 2483471120 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 WEST MAIN ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483476110 | ||||||||
| FaxNumber: | 2483471120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | PERIARD | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | AGENT PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2483476110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSW LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801067292 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.