Provider Demographics
NPI:1053881524
Name:KRAJEWSKI-KIDD, KATIE LYNN (TLLP, LLMSW)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:KRAJEWSKI-KIDD
Suffix:
Gender:F
Credentials:TLLP, LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WING ST.
Mailing Address - Street 2:PO BOX 305
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1277
Practice Address - Country:US
Practice Address - Phone:313-656-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011102901041C0700X
MI6301017621103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical