Provider Demographics
NPI:1215067962
Name:ANDRULIS, KATHLEEN ANN (MA, LLP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:ANDRULIS
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 E 13 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3795
Mailing Address - Country:US
Mailing Address - Phone:586-274-0200
Mailing Address - Fax:
Practice Address - Street 1:3701 E 13 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-3795
Practice Address - Country:US
Practice Address - Phone:586-274-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004072103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical