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General NPI Number Information
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NPI Number | 1962759415
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Entity Type | Organization
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Legal Business Name | MIDWEST NEURO FORENSICS, PC
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 2609 METROPOLITAN PKWY SUITE 300
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-4216
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Country | US
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Telephone | 586-446-2225
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Fax | 586-446-2227
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Provider Business Mailing Address
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Address Line | 2609 METROPOLITAN PKWY SUITE 300
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-4216
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Country | US
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Telephone | 586-446-2225
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Fax | 586-446-2227
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KYLE R BONESTEEL
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Credential | PH.D
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Telephone | 630-969-3233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301013025
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License Number State | MI
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