Healthcare Provider Details

I. General information

NPI: 1891234902
Provider Name (Legal Business Name): KIM KAROL JANIS M.S., TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE STE 250
GRAND RAPIDS MI
49506-4364
US

IV. Provider business mailing address

1550 E BELTLINE AVE SE STE 250
GRAND RAPIDS MI
49506-4364
US

V. Phone/Fax

Practice location:
  • Phone: 616-558-5915
  • Fax:
Mailing address:
  • Phone: 616-558-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362008901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: