Provider Demographics
NPI:1720434442
Name:GEDA, KYLE (AUD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GEDA
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:588 E LAKEWOOD BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2023
Practice Address - Country:US
Practice Address - Phone:616-494-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000731231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist