Provider Demographics
NPI:1942027412
Name:MCKIMMY, DUSTIN RAYMOND (LLC)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RAYMOND
Last Name:MCKIMMY
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6720 LANSDOWN DR
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-9430
Mailing Address - Country:US
Mailing Address - Phone:517-899-0572
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE B110
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8468
Practice Address - Country:US
Practice Address - Phone:517-657-3533
Practice Address - Fax:517-580-0530
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023857101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health