Healthcare Provider Details

I. General information

NPI: 1790132074
Provider Name (Legal Business Name): KELLY JO HIGGS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-6363
  • Fax:
Mailing address:
  • Phone: 616-281-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092377
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: