Healthcare Provider Details

I. General information

NPI: 1407378417
Provider Name (Legal Business Name): KALYN LEE JUSTICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N KENTUCKY AVE
WEST PLAINS MO
65775-2029
US

IV. Provider business mailing address

2159 WILDFIELD DR NE
GRAND RAPIDS MI
49505-6323
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-9111
  • Fax:
Mailing address:
  • Phone: 248-884-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201011116
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2023011622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: