Provider Demographics
NPI:1124124060
Name:HANSEN-DUELL, KYMBRA R (LMSW)
Entity type:Individual
Prefix:
First Name:KYMBRA
Middle Name:R
Last Name:HANSEN-DUELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:700 HAMMOND RD E STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8641
Practice Address - Country:US
Practice Address - Phone:231-947-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801070584104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ38961Medicare UPIN
MID16222140Medicare ID - Type UnspecifiedMEDICARE