Provider Demographics
NPI:1104427368
Name:NIEVES, KIZZY
Entity type:Individual
Prefix:
First Name:KIZZY
Middle Name:
Last Name:NIEVES
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 1:52280 CEDAR MILL DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-5658
Mailing Address - Country:US
Mailing Address - Phone:313-346-7966
Mailing Address - Fax:
Practice Address - Street 1:52280 CEDAR MILL DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-5658
Practice Address - Country:US
Practice Address - Phone:313-346-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011063871041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical