Healthcare Provider Details

I. General information

NPI: 1083471890
Provider Name (Legal Business Name): KODIE CILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 MEADOWVIEW DR
NORTON SHORES MI
49441-7011
US

IV. Provider business mailing address

1327 MEADOWVIEW DR
NORTON SHORES MI
49441-7011
US

V. Phone/Fax

Practice location:
  • Phone: 231-638-9165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: