Provider Demographics
NPI:1083973549
Name:KORMOS, CARLEEN ANNA (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:CARLEEN
Middle Name:ANNA
Last Name:KORMOS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 LYON ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5607
Mailing Address - Country:US
Mailing Address - Phone:616-451-2039
Mailing Address - Fax:616-451-3590
Practice Address - Street 1:324 LYON ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5607
Practice Address - Country:US
Practice Address - Phone:616-451-2039
Practice Address - Fax:616-451-3590
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801092795101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)