Provider Demographics
NPI:1033939061
Name:BROWN-PENNINGTON, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:BROWN-PENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23381 PORTAGE WAY APT 2006
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3296
Mailing Address - Country:US
Mailing Address - Phone:734-678-3455
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE STE 282
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5184
Practice Address - Country:US
Practice Address - Phone:734-743-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851118297101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health