Provider Demographics
NPI:1255844007
Name:KUZICH, KAMERON L
Entity Type:Individual
Prefix:
First Name:KAMERON
Middle Name:L
Last Name:KUZICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 N ROESSLER ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2837
Mailing Address - Country:US
Mailing Address - Phone:734-497-7083
Mailing Address - Fax:
Practice Address - Street 1:6267 WEBSTER CHURCH RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-9659
Practice Address - Country:US
Practice Address - Phone:734-252-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2018-03-17
Deactivation Date:2017-11-14
Deactivation Code:
Reactivation Date:2017-11-21
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty