Provider Demographics
NPI:1831538198
Name:KAZA-EGAN, MANJULA
Entity type:Individual
Prefix:
First Name:MANJULA
Middle Name:
Last Name:KAZA-EGAN
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 1:13116 BALFOUR AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13116 BALFOUR AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1701
Practice Address - Country:US
Practice Address - Phone:248-200-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093902104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker