Provider Demographics
NPI:1427558162
Name:KAIAFAS, CAROLYN (PT)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:KAIAFAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15777 NORTHLINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2300
Mailing Address - Country:US
Mailing Address - Phone:734-246-8125
Mailing Address - Fax:734-246-8113
Practice Address - Street 1:15777 NORTHLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2300
Practice Address - Country:US
Practice Address - Phone:734-246-8125
Practice Address - Fax:734-246-8113
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487605168Medicaid