Basic Information
| Provider Information | |||||||||
| NPI: | 1992985824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAFLEUR | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | MA, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29750 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480822607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867773200 | ||||||||
| FaxNumber: | 5867773200 | ||||||||
| Practice Location | |||||||||
| Address1: | 29750 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480822607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867773200 | ||||||||
| FaxNumber: | 5867777855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | 6301013687 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |