Provider Demographics
NPI:1467196931
Name:MCKNIGHT, KASSIE L
Entity Type:Individual
Prefix:
First Name:KASSIE
Middle Name:L
Last Name:MCKNIGHT
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 1:499 FRAZIER ST
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218
Mailing Address - Country:US
Mailing Address - Phone:313-459-9219
Mailing Address - Fax:
Practice Address - Street 1:499 FRAZIER ST
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218
Practice Address - Country:US
Practice Address - Phone:313-459-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0055475256OtherMEDICAID