Provider Demographics
NPI:1265063077
Name:LOISELLE, KATI LANE
Entity type:Individual
Prefix:
First Name:KATI
Middle Name:LANE
Last Name:LOISELLE
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 1:301 NEBOBISH AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1158
Mailing Address - Country:US
Mailing Address - Phone:989-245-1997
Mailing Address - Fax:
Practice Address - Street 1:100 MAYER RD
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1334
Practice Address - Country:US
Practice Address - Phone:989-652-4663
Practice Address - Fax:989-652-3279
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801101040104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty