Provider Demographics
NPI:1669875779
Name:VARBONCOEUR, KATHY (CADC, SST)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:VARBONCOEUR
Suffix:
Gender:F
Credentials:CADC, SST
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:LYN
Other - Last Name:KITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC, SST
Mailing Address - Street 1:18724 ELLENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9541
Mailing Address - Country:US
Mailing Address - Phone:231-740-9621
Mailing Address - Fax:
Practice Address - Street 1:1823 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2608
Practice Address - Country:US
Practice Address - Phone:231-728-2138
Practice Address - Fax:231-722-4771
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803058152174400000X
MI2-00422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist