Provider Demographics
NPI:1942586086
Name:KNACK, T MICHAEL (PH D)
Entity Type:Individual
Prefix:DR
First Name:T MICHAEL
Middle Name:
Last Name:KNACK
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11254 LAKE CIRCLE DR N
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-9454
Mailing Address - Country:US
Mailing Address - Phone:989-981-0731
Mailing Address - Fax:
Practice Address - Street 1:4901 TOWNE CTR
Practice Address - Street 2:STE 205
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2841
Practice Address - Country:US
Practice Address - Phone:989-921-5715
Practice Address - Fax:989-921-5960
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical