Provider Demographics
NPI:1669961363
Name:KINGKITTISACK, HANNAH (LBA, TLLP)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:KINGKITTISACK
Suffix:
Gender:F
Credentials:LBA, TLLP
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:RIESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2675 FINI DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48380-3960
Mailing Address - Country:US
Mailing Address - Phone:810-599-0396
Mailing Address - Fax:
Practice Address - Street 1:16500 TIREMAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3629
Practice Address - Country:US
Practice Address - Phone:313-451-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6362010066103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician