Healthcare Provider Details

I. General information

NPI: 1053779496
Provider Name (Legal Business Name): KIMBERLY CULP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2016
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MONROE AVE NW SUITE 400
GRAND RAPIDS MI
49503-2211
US

IV. Provider business mailing address

2180 HIGHLANDER DR SE
KENTWOOD MI
49508-5031
US

V. Phone/Fax

Practice location:
  • Phone: 616-929-0017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014130
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: