Provider Demographics
NPI:1740530773
Name:PADULA, KATIE ALYSSA (MA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ALYSSA
Last Name:PADULA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20174 WINDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3524
Mailing Address - Country:US
Mailing Address - Phone:810-614-8760
Mailing Address - Fax:
Practice Address - Street 1:29750 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2607
Practice Address - Country:US
Practice Address - Phone:586-777-3200
Practice Address - Fax:586-777-7855
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional