Provider Demographics
NPI:1902932403
Name:VAZZANO, KRISTINE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:MARIE
Last Name:VAZZANO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:TIPPEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3910 TELEGRAPH RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1420
Mailing Address - Country:US
Mailing Address - Phone:248-686-0346
Mailing Address - Fax:248-686-0344
Practice Address - Street 1:3910 TELEGRAPH RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-1420
Practice Address - Country:US
Practice Address - Phone:248-686-0346
Practice Address - Fax:248-686-0344
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical