Healthcare Provider Details

I. General information

NPI: 1033021514
Provider Name (Legal Business Name): KELLY GOOSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 MADISON ST
MUSKEGON MI
49442-5251
US

IV. Provider business mailing address

2700 BAKER ST
MUSKEGON MI
49444-2157
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-6384
  • Fax: 231-737-0534
Mailing address:
  • Phone: 231-737-1335
  • Fax: 231-737-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451025233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: