Provider Demographics
NPI:1457419244
Name:KINZIE, MARY (MSW LMSW ACSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KINZIE
Suffix:
Gender:F
Credentials:MSW LMSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36975 UTICA ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036
Mailing Address - Country:US
Mailing Address - Phone:586-226-3440
Mailing Address - Fax:586-226-3672
Practice Address - Street 1:45445 MOUND
Practice Address - Street 2:SOUTE 109
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317
Practice Address - Country:US
Practice Address - Phone:586-254-5660
Practice Address - Fax:586-254-0622
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010358651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM10270002Medicare ID - Type Unspecified