Healthcare Provider Details

I. General information

NPI: 1386639870
Provider Name (Legal Business Name): KRISSA KIRBY PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 LEONARD ST NE
GRAND RAPIDS MI
49505-5650
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-9619
  • Fax:
Mailing address:
  • Phone: 616-455-5000
  • Fax: 616-455-5000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6399
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number390
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: