Healthcare Provider Details

I. General information

NPI: 1720869357
Provider Name (Legal Business Name): KAELA LOU CARROLL LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

IV. Provider business mailing address

23 LAMOREAUX DR NW
COMSTOCK PARK MI
49321-9120
US

V. Phone/Fax

Practice location:
  • Phone: 231-414-5811
  • Fax:
Mailing address:
  • Phone: 231-414-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851114615
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: