Healthcare Provider Details

I. General information

NPI: 1023978350
Provider Name (Legal Business Name): KYLENE DALTON-KOONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 BURTON ST SE STE 103
GRAND RAPIDS MI
49546-4833
US

IV. Provider business mailing address

1919 CHAMBERLAIN AVE SE
GRAND RAPIDS MI
49506-4638
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-0671
  • Fax:
Mailing address:
  • Phone: 616-229-0671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089199
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: