Healthcare Provider Details

I. General information

NPI: 1457109977
Provider Name (Legal Business Name): KAITLYN MARIE ANDERSON LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

119 FULLER AVE SE APT B
GRAND RAPIDS MI
49506-1635
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7207
  • Fax:
Mailing address:
  • Phone: 910-875-3588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023290
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: