Provider Demographics
NPI:1609064690
Name:EMRICH, KATHLEEN AGNES (APRN,BC,NP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:AGNES
Last Name:EMRICH
Suffix:
Gender:F
Credentials:APRN,BC,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PETERBORO ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2722
Mailing Address - Country:US
Mailing Address - Phone:313-831-3160
Mailing Address - Fax:313-831-2604
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:313-831-2604
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704080902364SP0809X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4754509Medicaid