Basic Information
| Provider Information | |||||||||
| NPI: | 1932406659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138332500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138332500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| 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 | 101Y00000X | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YP1600X | MI | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YP2500X | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.