Healthcare Provider Details

I. General information

NPI: 1689580276
Provider Name (Legal Business Name): KIRIVON PEN CARLSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIRI PEN CARLSON LMFT

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 OTTAWA AVE NW STE 425
GRAND RAPIDS MI
49503-2648
US

IV. Provider business mailing address

80 OTTAWA AVE NW STE 425
GRAND RAPIDS MI
49503-2648
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-0022
  • Fax:
Mailing address:
  • Phone: 616-920-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101007725
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: