Healthcare Provider Details

I. General information

NPI: 1124693239
Provider Name (Legal Business Name): KELSEY ANNA LANTIS LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE STE 300
JACKSON MI
49202-2180
US

IV. Provider business mailing address

1545 MEADOW LN
HILLSDALE MI
49242-8712
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax:
Mailing address:
  • Phone: 517-610-6723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: