Provider Demographics
NPI:1447517214
Name:KRAUSE, KYLENE (PHD, DLLP)
Entity type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:KRAUSE
Suffix:
Gender:F
Credentials:PHD, DLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 WASHINGTON AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7141
Mailing Address - Country:US
Mailing Address - Phone:616-355-3926
Mailing Address - Fax:
Practice Address - Street 1:854 WASHINGTON AVE STE 330
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7141
Practice Address - Country:US
Practice Address - Phone:616-355-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical