Provider Demographics
NPI:1255179446
Name:GUGLIOTTA, KIMBERLEE MARIE
Entity type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:MARIE
Last Name:GUGLIOTTA
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 1:11757 HARDWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-8165
Mailing Address - Country:US
Mailing Address - Phone:616-710-1066
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE STE 302
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9350
Practice Address - Country:US
Practice Address - Phone:616-226-6522
Practice Address - Fax:616-608-6751
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional