Provider Demographics
NPI:1982424941
Name:VANDERMEULEN, KYRA
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:VANDERMEULEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYRA
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33129 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3788
Mailing Address - Country:US
Mailing Address - Phone:630-538-6011
Mailing Address - Fax:
Practice Address - Street 1:215 ANN ARBOR RD W STE 206
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2251
Practice Address - Country:US
Practice Address - Phone:734-335-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023789101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health