Provider Demographics
NPI:1972905669
Name:WYSZACKI DURHAM, KATHLEEN HELEN (BS, BA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:HELEN
Last Name:WYSZACKI DURHAM
Suffix:
Gender:F
Credentials:BS, BA
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:HELEN
Other - Last Name:WYSZACKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21190 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24424 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3653
Practice Address - Country:US
Practice Address - Phone:313-255-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)