Provider Demographics
NPI:1740599216
Name:KANISZEWSKI, MARIA
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:KANISZEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2715 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9294
Practice Address - Country:US
Practice Address - Phone:989-366-1118
Practice Address - Fax:989-366-9420
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1764585101Y00000X
MIL1815378103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101Y00000XBehavioral Health & Social Service ProvidersCounselor