Healthcare Provider Details

I. General information

NPI: 1063366524
Provider Name (Legal Business Name): KELSI ANNE TYSZKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 CASCADE RD SE
GRAND RAPIDS MI
49546-8384
US

IV. Provider business mailing address

2950 HOLTON RD
TWIN LAKE MI
49457-9760
US

V. Phone/Fax

Practice location:
  • Phone: 231-750-2467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: