Healthcare Provider Details

I. General information

NPI: 1508414368
Provider Name (Legal Business Name): KYLIE MARIE BADER LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLIE MARIE DEKRYGER

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 N 10TH ST STE 110
KALAMAZOO MI
49009-5733
US

IV. Provider business mailing address

121 CRESCENT ST
ALLEGAN MI
49010-1412
US

V. Phone/Fax

Practice location:
  • Phone: 269-375-4363
  • Fax:
Mailing address:
  • Phone: 269-312-2007
  • Fax: 269-375-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801104448
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109983
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: