Provider Demographics
NPI:1093350985
Name:KESTERSON, KATIE ANN
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:KESTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26100 CUBBERNESS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3308
Mailing Address - Country:US
Mailing Address - Phone:586-864-4665
Mailing Address - Fax:
Practice Address - Street 1:42815 GARFIELD RD STE 201
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1143
Practice Address - Country:US
Practice Address - Phone:586-333-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017933101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health