Provider Demographics
NPI:1780823971
Name:TITHOF, KATHLEEN ANN (LLMSW, CTRS, CBIS)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:TITHOF
Suffix:
Gender:F
Credentials:LLMSW, CTRS, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 MANCELONA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-953-3238
Mailing Address - Fax:
Practice Address - Street 1:2775 EAST LANSING DRIVE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-332-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010863331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38418OtherCERTIFIED THERAPEUTIC RECREATION SPECIALIST
MI6801086333OtherBOARD OF SOCIAL WORK LIMITED LICENSE