Provider Demographics
NPI:1467578286
Name:KALIL, KATHLEEN MARY (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARY
Last Name:KALIL
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24940 FAIRMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1584
Mailing Address - Country:US
Mailing Address - Phone:313-274-3500
Mailing Address - Fax:
Practice Address - Street 1:24940 FAIRMOUNT DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1584
Practice Address - Country:US
Practice Address - Phone:313-274-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003906103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF33321OtherBLUE CROSS PROVIER NUMBER