Provider Demographics
NPI:1356050850
Name:BOONZAAYER, LYDIA CM
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:CM
Last Name:BOONZAAYER
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 1:3667 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9502
Mailing Address - Country:US
Mailing Address - Phone:213-807-0882
Mailing Address - Fax:
Practice Address - Street 1:2019 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1630
Practice Address - Country:US
Practice Address - Phone:213-807-0882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022584101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor