Healthcare Provider Details

I. General information

NPI: 1073665311
Provider Name (Legal Business Name): KATHLEEN MARIE WELLER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE STE 255
GRAND RAPIDS MI
49506-4362
US

IV. Provider business mailing address

1550 E BELTLINE AVE SE STE 255
GRAND RAPIDS MI
49506-4362
US

V. Phone/Fax

Practice location:
  • Phone: 616-747-0700
  • Fax:
Mailing address:
  • Phone: 616-747-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011108
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: