Provider Demographics
NPI:1083960488
Name:HOLM, KELLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:HOLM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:EATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 HAZEN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-2008
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-6523
Practice Address - Street 1:801 HAZEN ST
Practice Address - Street 2:SUITE C
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-2008
Practice Address - Country:US
Practice Address - Phone:269-657-5574
Practice Address - Fax:269-657-6523
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010803301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical