Provider Demographics
NPI:1699551366
Name:KAIDBAY, RAY LYNN (DTLLP)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:LYNN
Last Name:KAIDBAY
Suffix:
Gender:F
Credentials:DTLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49982 ASH CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6380
Mailing Address - Country:US
Mailing Address - Phone:734-890-0920
Mailing Address - Fax:
Practice Address - Street 1:17515 W 9 MILE RD STE 240
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4423
Practice Address - Country:US
Practice Address - Phone:248-579-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000774103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical