Provider Demographics
NPI:1720522121
Name:VANDENBOOM, KAYLA (CTRS)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:VANDENBOOM
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 1:9948 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:REESE
Mailing Address - State:MI
Mailing Address - Zip Code:48757-9547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9948 CENTER ST
Practice Address - Street 2:
Practice Address - City:REESE
Practice Address - State:MI
Practice Address - Zip Code:48757-9547
Practice Address - Country:US
Practice Address - Phone:989-297-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59652225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist