1326129750 NPI number — MS. KIM BETH KETOLA LMSW

Table of content: MS. KIM BETH KETOLA LMSW (NPI 1326129750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326129750 NPI number — MS. KIM BETH KETOLA LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETOLA
Provider First Name:
KIM
Provider Middle Name:
BETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326129750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5316 BREEZE HILL PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48098-2725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-216-4553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39520 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 233
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304-5054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-216-4553
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2006

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: 1041C0700X , with the licence number:  6801066233 , 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)

  • Identifier: 0899799 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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