Provider Demographics
NPI:1043078157
Name:JOHNSON, KELLY ANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 WEALTHY ST SE APT B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1589
Mailing Address - Country:US
Mailing Address - Phone:616-690-3034
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 222
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3262
Practice Address - Country:US
Practice Address - Phone:616-490-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011157311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty