Provider Demographics
NPI:1871144741
Name:HAIST, KATLYN JANELLE
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:JANELLE
Last Name:HAIST
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 1:4324 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1126
Mailing Address - Country:US
Mailing Address - Phone:810-931-4954
Mailing Address - Fax:
Practice Address - Street 1:4500 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2676
Practice Address - Country:US
Practice Address - Phone:810-262-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006007225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant