Provider Demographics
NPI:1174258826
Name:KAZMIERCZAK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KAZMIERCZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2890
Mailing Address - Country:US
Mailing Address - Phone:313-689-5188
Mailing Address - Fax:
Practice Address - Street 1:1360 PORTER ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2890
Practice Address - Country:US
Practice Address - Phone:313-689-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician