Provider Demographics
NPI:1245707694
Name:VAN DUSEN, KYLI JAYMES (LAC)
Entity type:Individual
Prefix:
First Name:KYLI
Middle Name:JAYMES
Last Name:VAN DUSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 CLUBHOUSE WAY APT 4
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-3428
Mailing Address - Country:US
Mailing Address - Phone:605-850-9108
Mailing Address - Fax:
Practice Address - Street 1:1231 N 29TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0147
Practice Address - Country:US
Practice Address - Phone:406-248-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-32657101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)