Provider Demographics
NPI:1790597151
Name:GEORGE, KAILIE
Entity type:Individual
Prefix:
First Name:KAILIE
Middle Name:
Last Name:GEORGE
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 1:3401 DEERING DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8681
Mailing Address - Country:US
Mailing Address - Phone:919-426-0270
Mailing Address - Fax:
Practice Address - Street 1:155 SWEET ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4601
Practice Address - Country:US
Practice Address - Phone:919-426-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20213101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty