Healthcare Provider Details

I. General information

NPI: 1407389604
Provider Name (Legal Business Name): KELLY JO CRABB LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY JO MCCALEB LMSW

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4829 E BELTLINE AVE NE STE 100
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

4829 E BELTLINE AVE NE STE 100
GRAND RAPIDS MI
49525-9349
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-3301
  • Fax:
Mailing address:
  • Phone: 616-364-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: