Provider Demographics
NPI:1255696506
Name:WILSON-GROVES, KAYLA ANN (CTRS)
Entity type:Individual
Prefix:MISS
First Name:KAYLA
Middle Name:ANN
Last Name:WILSON-GROVES
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18248 FLEUR DE LIS
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1286
Mailing Address - Country:US
Mailing Address - Phone:734-735-1332
Mailing Address - Fax:
Practice Address - Street 1:18248 FLEUR DE LIS
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1286
Practice Address - Country:US
Practice Address - Phone:734-735-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59854174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist