Healthcare Provider Details

I. General information

NPI: 1043078157
Provider Name (Legal Business Name): KELLY ANNE JOHNSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 222
GRAND RAPIDS MI
49503-3262
US

IV. Provider business mailing address

930 WEALTHY ST SE APT B
GRAND RAPIDS MI
49506-1589
US

V. Phone/Fax

Practice location:
  • Phone: 616-490-3468
  • Fax:
Mailing address:
  • Phone: 616-690-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: