Provider Demographics
NPI:1750484283
Name:MARTIN, KATHLEEN SUSAN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUSAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:SUSAN
Other - Last Name:ANDREAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3155 MYDDLETON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1224
Mailing Address - Country:US
Mailing Address - Phone:248-280-3940
Mailing Address - Fax:
Practice Address - Street 1:115 N CENTER ST
Practice Address - Street 2:HEGIRA NORTHVILLE COUNSELING CENTER
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1469
Practice Address - Country:US
Practice Address - Phone:248-347-3470
Practice Address - Fax:248-347-2242
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008985101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor