Provider Demographics
NPI:1265630586
Name:STAUGAENO, KATHLEEN J (MS)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:J
Last Name:STAUGAENO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5388 FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3479
Mailing Address - Country:US
Mailing Address - Phone:248-620-1168
Mailing Address - Fax:248-620-1168
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013278103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical