Healthcare Provider Details

I. General information

NPI: 1003413352
Provider Name (Legal Business Name): KAILE VIDETICH LLMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 KENMOOR AVE SE STE 103
GRAND RAPIDS MI
49546-8626
US

IV. Provider business mailing address

1026 COOPER AVE SE
GRAND RAPIDS MI
49507-1459
US

V. Phone/Fax

Practice location:
  • Phone: 616-330-2330
  • Fax: 616-600-0360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4151001001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: