Provider Demographics
NPI:1154685212
Name:MUIZELAAR, KELLY JO (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:MUIZELAAR
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 1:412 NAKOMA DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-7227
Mailing Address - Country:US
Mailing Address - Phone:616-648-4624
Mailing Address - Fax:
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-793-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010844031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical