Provider Demographics
NPI:1720589740
Name:HAAS, KATHLEEN GRACE (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:HAAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13157 ROBINS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-8975
Mailing Address - Country:US
Mailing Address - Phone:231-881-4503
Mailing Address - Fax:
Practice Address - Street 1:14700 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1931
Practice Address - Country:US
Practice Address - Phone:231-547-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI38-1459366282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural