Healthcare Provider Details

I. General information

NPI: 1912690868
Provider Name (Legal Business Name): KELSEY ENRIQUEZ LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 44TH ST SE
GRAND RAPIDS MI
49512-3945
US

IV. Provider business mailing address

430 SOMERSET DR NE
GRAND RAPIDS MI
49503-3900
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-9192
  • Fax:
Mailing address:
  • Phone: 517-896-7576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851116603
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: