Provider Demographics
NPI:1164108916
Name:MYLUM, KIONNI EMPERESS
Entity Type:Individual
Prefix:
First Name:KIONNI
Middle Name:EMPERESS
Last Name:MYLUM
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 1:19157 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-4200
Mailing Address - Country:US
Mailing Address - Phone:313-296-2045
Mailing Address - Fax:313-296-2045
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-1370
Practice Address - Fax:248-712-0438
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician