Provider Demographics
NPI:1902507759
Name:CONLIN, KATHRYN JOANNE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JOANNE
Last Name:CONLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6294 KLAM RD
Mailing Address - Street 2:
Mailing Address - City:OTTER LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48464-9659
Mailing Address - Country:US
Mailing Address - Phone:810-441-4012
Mailing Address - Fax:
Practice Address - Street 1:690 N LAKE PLEASANT RD
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:MI
Practice Address - Zip Code:48412-9770
Practice Address - Country:US
Practice Address - Phone:810-664-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician