Provider Demographics
NPI:1588953335
Name:KITZMILLER, DIANA THERESE (MA, LLP)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:THERESE
Last Name:KITZMILLER
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 1:55 MAUMEE TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1221
Mailing Address - Country:US
Mailing Address - Phone:248-705-5986
Mailing Address - Fax:
Practice Address - Street 1:55 MAUMEE TRL
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-1221
Practice Address - Country:US
Practice Address - Phone:248-705-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010475103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist