Provider Demographics
NPI:1285919530
Name:KAUFMAN, THERESE (LMSW)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:KAUFMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 LAKE LEELANAU DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9544
Mailing Address - Country:US
Mailing Address - Phone:231-242-3254
Mailing Address - Fax:231-421-7535
Practice Address - Street 1:421 N SAINT JOSEPH ST # 202
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-5111
Practice Address - Country:US
Practice Address - Phone:231-242-3254
Practice Address - Fax:231-421-7535
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093640104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16222Medicare UPIN