Healthcare Provider Details

I. General information

NPI: 1992163281
Provider Name (Legal Business Name): KELSEY WOOLNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY DAVIS

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date: 05/22/2018
Reactivation Date: 06/14/2018

III. Provider practice location address

6500 BYRON CENTER AVE SW
BYRON CENTER MI
49315-9080
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-6311
  • Fax:
Mailing address:
  • Phone: 616-281-6372
  • Fax: 616-281-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6351004436
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberF1350625
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: