Healthcare Provider Details

I. General information

NPI: 1962772061
Provider Name (Legal Business Name): KURT DAVID KELLER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

IV. Provider business mailing address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax: 616-242-6057
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-242-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089663
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: