Basic Information
| Provider Information | |||||||||
| NPI: | 1356620793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 E JOLLY RD STE 210 | ||||||||
| Address2: | ATTN: DIANA SMITH | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468119 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Practice Location | |||||||||
| Address1: | 5303 S CEDAR ST | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489113800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468059 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089924 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.