Provider Demographics
NPI:1174314405
Name:DITTENBER, KYLIE E
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:E
Last Name:DITTENBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9790 GRATIOT RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-9473
Mailing Address - Country:US
Mailing Address - Phone:989-241-3671
Mailing Address - Fax:
Practice Address - Street 1:9790 GRATIOT RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48609-9473
Practice Address - Country:US
Practice Address - Phone:989-241-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511201581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical