Provider Demographics
NPI:1750165106
Name:WIETEN, KAYLEE (LLMSW)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:WIETEN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:
Other - Last Name:MCWILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:518 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2127
Mailing Address - Country:US
Mailing Address - Phone:616-843-5577
Mailing Address - Fax:
Practice Address - Street 1:8 W WALTON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49440-1360
Practice Address - Country:US
Practice Address - Phone:231-722-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511173361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical