Healthcare Provider Details

I. General information

NPI: 1205554615
Provider Name (Legal Business Name): KYLE HANDRICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 E BELTLINE AVE NE STE 400
GRAND RAPIDS MI
49525-9787
US

IV. Provider business mailing address

1510 DERBY DR NW
GRAND RAPIDS MI
49504-2678
US

V. Phone/Fax

Practice location:
  • Phone: 989-745-9133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: