Provider Demographics
NPI:1053474031
Name:SEITZ, KATHLEEN WONG (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:WONG
Last Name:SEITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 THORESON RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49664
Mailing Address - Country:US
Mailing Address - Phone:231-334-3677
Mailing Address - Fax:
Practice Address - Street 1:921 WEST 11TH ST
Practice Address - Street 2:STE 1E
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-946-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006659103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M91300Medicare ID - Type Unspecified