1215496153 NPI number — KATIE LYNN MULLIGAN SMITH AT, ATC

Table of content: KATIE LYNN MULLIGAN SMITH AT, ATC (NPI 1215496153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215496153 NPI number — KATIE LYNN MULLIGAN SMITH AT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIGAN SMITH
Provider First Name:
KATIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MULLIGAN
Provider Other First Name:
KATIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AT, ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215496153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1968 LAC DU MONT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASLETT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48840-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1968 LAC DU MONT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASLETT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48840-9506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-719-2081
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  2601001034 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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