Healthcare Provider Details

I. General information

NPI: 1366819815
Provider Name (Legal Business Name): KELLIE VANASSCHE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 SYLVAN AVE STE 1110
ENGLEWOOD CLIFFS NJ
07632-3118
US

IV. Provider business mailing address

15930 19 MILE RD
CLINTON TWP MI
48038-1155
US

V. Phone/Fax

Practice location:
  • Phone: 646-873-6600
  • Fax: 646-859-4440
Mailing address:
  • Phone: 586-464-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: