Healthcare Provider Details

I. General information

NPI: 1043057219
Provider Name (Legal Business Name): KYRA ROBERTS LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2024
Last Update Date: 11/05/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 CLAYSTONE ST SE STE G32
GRAND RAPIDS MI
49546-5794
US

IV. Provider business mailing address

51771 PLEASANT DR
MATTAWAN MI
49071
US

V. Phone/Fax

Practice location:
  • Phone: 352-238-1608
  • Fax:
Mailing address:
  • Phone: 352-238-1608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023959
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: