Provider Demographics
NPI:1164384715
Name:IMPASTATO, KRISTIN MARIE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:IMPASTATO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N WILLIAMSBURY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2519
Mailing Address - Country:US
Mailing Address - Phone:248-613-7665
Mailing Address - Fax:248-613-7665
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-599-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-02
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty