Provider Demographics
NPI:1144759655
Name:DECKER, KIMBER GLENN (MA)
Entity Type:Individual
Prefix:MR
First Name:KIMBER
Middle Name:GLENN
Last Name:DECKER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 E BELTLINE AVE NE STE 303
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9350
Mailing Address - Country:US
Mailing Address - Phone:616-320-4664
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE STE 303
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9350
Practice Address - Country:US
Practice Address - Phone:616-320-4664
Practice Address - Fax:833-469-2110
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP1600X
MI101YM0800X
MI6401016108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral