Healthcare Provider Details

I. General information

NPI: 1720787476
Provider Name (Legal Business Name): KIMBERLEY ANNE HEWITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 PEACH RIDGE AVE NW
GRAND RAPIDS MI
49544-9793
US

IV. Provider business mailing address

4311 PEACH RIDGE AVE NW
GRAND RAPIDS MI
49544-9793
US

V. Phone/Fax

Practice location:
  • Phone: 616-405-9398
  • Fax:
Mailing address:
  • Phone: 616-405-9398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014043
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: