Provider Demographics
NPI:1548777055
Name:WESLEY, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WESLEY
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 1:21500 NORTHWESTERN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2181
Mailing Address - Country:US
Mailing Address - Phone:248-485-8455
Mailing Address - Fax:
Practice Address - Street 1:21500 NORTHWESTERN
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-548-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical