Provider Demographics
NPI:1629057906
Name:FOUCHE BRAZZLE, KATHLEEN MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:FOUCHE BRAZZLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5640 W MAPLE RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3716
Mailing Address - Country:US
Mailing Address - Phone:248-932-8585
Mailing Address - Fax:248-932-0358
Practice Address - Street 1:5640 W MAPLE RD
Practice Address - Street 2:SUITE 310
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3716
Practice Address - Country:US
Practice Address - Phone:248-932-0290
Practice Address - Fax:248-932-0358
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010520262084P0800X, 2084P0804X
GA0498752084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF68744Medicare UPIN