Provider Demographics
NPI:1043057219
Name:ROBERTS, KYRA (LCMHCA)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51771 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071
Mailing Address - Country:US
Mailing Address - Phone:352-238-1608
Mailing Address - Fax:
Practice Address - Street 1:3351 CLAYSTONE ST SE STE G32
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5794
Practice Address - Country:US
Practice Address - Phone:352-238-1608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-13
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023959101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health