Provider Demographics
NPI:1407262066
Name:KOSTANECKI, NATALIE M (LMSW)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:M
Last Name:KOSTANECKI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:NATAILE
Other - Middle Name:M
Other - Last Name:MIKKOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21885 DUNHAM ROAD SUITE 1
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1610
Mailing Address - Country:US
Mailing Address - Phone:586-469-5950
Mailing Address - Fax:
Practice Address - Street 1:21885 DUNHAM ROAD SUITE 1
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1610
Practice Address - Country:US
Practice Address - Phone:586-469-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010969701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical