MEDICARE: ALEXIS BRIANNA KIRK LLPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6451023801	MI

General Provider Information

NPI Number	:	1023856192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS BRIANNA KIRK LLPC

Provider Business Mailing Address
First Line	:	15 OTTAWA AVE NW APT 704
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4833
Country	:	US
Telephone Number	:	757-775-2716
Fax Number	:

Provider Business Practice Location Address
First Line	:	4764 FULTON ST E STE 204
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-9086
Country	:	US
Telephone Number	:	616-541-9951
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/15/2024

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