Healthcare Provider Details

I. General information

NPI: 1851427124
Provider Name (Legal Business Name): KIZOMBO LAMBERT KALUMBULA PH.D. (C)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE SUITE 280
GRAND RAPIDS MI
49546-5938
US

IV. Provider business mailing address

4133 KENTRIDGE DR SE
GRAND RAPIDS MI
49508-3705
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-7331
  • Fax:
Mailing address:
  • Phone: 616-281-8747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301011825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: