Healthcare Provider Details

I. General information

NPI: 1487928511
Provider Name (Legal Business Name): SHELLEY HOMOLKA MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 36TH ST SE
GRAND RAPIDS MI
49512-8193
US

IV. Provider business mailing address

3250 36TH ST SE
GRAND RAPIDS MI
49512-8193
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-3476
  • Fax:
Mailing address:
  • Phone: 616-965-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010905
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: