Healthcare Provider Details

I. General information

NPI: 1891457537
Provider Name (Legal Business Name): KELLY HAFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 HALL ST SE
GRAND RAPIDS MI
49506-3568
US

IV. Provider business mailing address

2530 HALL ST SE
GRAND RAPIDS MI
49506-3568
US

V. Phone/Fax

Practice location:
  • Phone: 757-675-2939
  • Fax:
Mailing address:
  • Phone: 757-675-2939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: