Provider Demographics
NPI:1073541082
Name:PERIARD, KRISTIN MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:PERIARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:MELOTIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LMSW
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:#202
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1586
Practice Address - Country:US
Practice Address - Phone:248-347-6110
Practice Address - Fax:248-347-1120
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801067292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP16454Medicare UPIN
MIQ26426190Medicare ID - Type Unspecified