Provider Demographics
NPI:1972007771
Name:LAVICTOIRE, KAYLE ANN (DPT)
Entity Type:Individual
Prefix:
First Name:KAYLE
Middle Name:ANN
Last Name:LAVICTOIRE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8328
Mailing Address - Country:US
Mailing Address - Phone:616-252-1530
Mailing Address - Fax:
Practice Address - Street 1:5500 BURTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6711
Practice Address - Country:US
Practice Address - Phone:616-840-7529
Practice Address - Fax:616-840-9693
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501016490Medicaid