Provider Demographics
NPI:1609320084
Name:DALLAIRE, KRISTIN (MA, LLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:DALLAIRE
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:MICHEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 N RIVER ST STE A
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3815
Mailing Address - Country:US
Mailing Address - Phone:616-439-0392
Mailing Address - Fax:
Practice Address - Street 1:1440 TORREY RD STE E
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1340
Practice Address - Country:US
Practice Address - Phone:616-439-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI6301018325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program