Provider Demographics
NPI:1366579914
Name:THACKER, KRISTIN LYNN (BA)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LYNN
Last Name:THACKER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21005 SUNNYDALE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3143
Mailing Address - Country:US
Mailing Address - Phone:586-776-7784
Mailing Address - Fax:
Practice Address - Street 1:43740 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1139
Practice Address - Country:US
Practice Address - Phone:586-469-7629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker