Healthcare Provider Details

I. General information

NPI: 1578868030
Provider Name (Legal Business Name): KYLE LAVERNE WOODS B.A.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

114 N MILL ST
PLYMOUTH MI
48170-1444
US

V. Phone/Fax

Practice location:
  • Phone: 734-397-3088
  • Fax:
Mailing address:
  • Phone: 517-404-9234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: