Provider Demographics
NPI:1689282428
Name:PORTER-STOVER, KAYLEE RAE
Entity Type:Individual
Prefix:MRS
First Name:KAYLEE
Middle Name:RAE
Last Name:PORTER-STOVER
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 1:1817 RICHMAN RD
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-2216
Mailing Address - Country:US
Mailing Address - Phone:810-824-8487
Mailing Address - Fax:
Practice Address - Street 1:3245 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3498
Practice Address - Country:US
Practice Address - Phone:810-937-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician