Healthcare Provider Details

I. General information

NPI: 1992362347
Provider Name (Legal Business Name): KELLY AHTI, LMSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 CASCADE RD SE STE 2
GRAND RAPIDS MI
49546-8319
US

IV. Provider business mailing address

4519 CASCADE RD SE STE 2
GRAND RAPIDS MI
49546-8319
US

V. Phone/Fax

Practice location:
  • Phone: 616-724-4705
  • Fax:
Mailing address:
  • Phone: 616-724-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLY AHTI
Title or Position: MENTAL HEALTH THERAPIST
Credential: LMSW
Phone: 616-724-4705