Healthcare Provider Details

I. General information

NPI: 1851420855
Provider Name (Legal Business Name): JOYLYNN KILLGORE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOYLYNN LOBBEZOO LMSW

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 MEDICAL PARK DR SE
GRAND RAPIDS MI
49546-3607
US

IV. Provider business mailing address

16350 CEDAR SPRINGS AVE
SAND LAKE MI
49343-9466
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-0794
  • Fax:
Mailing address:
  • Phone: 616-696-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801081601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: