Provider Demographics
NPI:1043640493
Name:LICHTLE, KRISTIN (MA, LLP, PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LICHTLE
Suffix:
Gender:F
Credentials:MA, LLP, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22749 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3826
Mailing Address - Country:US
Mailing Address - Phone:505-588-8207
Mailing Address - Fax:
Practice Address - Street 1:906 FRANCISCAN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2416
Practice Address - Country:US
Practice Address - Phone:505-588-8207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015077103T00000X
NMPA-1478103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist