Healthcare Provider Details

I. General information

NPI: 1447893573
Provider Name (Legal Business Name): KEITH D HEAD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 EMMET ST
PETOSKEY MI
49770-2910
US

IV. Provider business mailing address

1424 STANDISH AVE APT 208C
PETOSKEY MI
49770-3066
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-5111
  • Fax:
Mailing address:
  • Phone: 231-215-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801121660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: