Provider Demographics
NPI:1376639500
Name:POWELL, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:POWELL
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 1:9490 PERE MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8387
Mailing Address - Country:US
Mailing Address - Phone:810-694-9155
Mailing Address - Fax:
Practice Address - Street 1:10785 S SAGINAW ST
Practice Address - Street 2:SUITE A, BLDG. E
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7003
Practice Address - Country:US
Practice Address - Phone:810-695-0055
Practice Address - Fax:810-695-6813
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional