Basic Information
| Provider Information | |||||||||
| NPI: | 1578288361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | I KALEIDOSCOPE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8892 LILLY DR | ||||||||
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| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481979658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164305902 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1785 W STADIUM BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481035285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348812723 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2022 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAKHAI | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | CATHERINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 7348812723 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.