Provider Demographics
NPI:1366947814
Name:MUSTAFAGA, KAYLE (LLMSW)
Entity type:Individual
Prefix:
First Name:KAYLE
Middle Name:
Last Name:MUSTAFAGA
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26670 E CARNEGIE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-6150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5303 S CEDAR ST STE 2
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3800
Practice Address - Country:US
Practice Address - Phone:517-346-8318
Practice Address - Fax:517-346-8420
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 251S00000X
MI6801103372104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health