Provider Demographics
NPI:1427599885
Name:KATHLEEN MICHAUD PHD LLC
Entity type:Organization
Organization Name:KATHLEEN MICHAUD PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCIAL PSYCOLOGIIST, SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-971-5806
Mailing Address - Street 1:2498 N STOKESBERRY PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5150
Mailing Address - Country:US
Mailing Address - Phone:208-971-5806
Mailing Address - Fax:208-629-1358
Practice Address - Street 1:2498 N STOKESBERRY PL
Practice Address - Street 2:SUITE 140
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5150
Practice Address - Country:US
Practice Address - Phone:208-971-5806
Practice Address - Fax:208-629-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1992997837Medicare PIN