Provider Demographics
NPI:1528575974
Name:KWASNICK, KIMBERLE LYNN (LLMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLE
Middle Name:LYNN
Last Name:KWASNICK
Suffix:
Gender:F
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 ALGONQUIN WAY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1001
Mailing Address - Country:US
Mailing Address - Phone:517-243-6426
Mailing Address - Fax:
Practice Address - Street 1:1422 W SAGINAW ST
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2434
Practice Address - Country:US
Practice Address - Phone:517-243-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006523106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist