Provider Demographics
NPI:1164703948
Name:KLINGENBERG, KELSEY (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KLINGENBERG
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 1:805 LEONARD ST. NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1138
Mailing Address - Country:US
Mailing Address - Phone:616-451-2021
Mailing Address - Fax:616-451-8936
Practice Address - Street 1:805 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1138
Practice Address - Country:US
Practice Address - Phone:616-451-2021
Practice Address - Fax:616-451-8936
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381358163Medicaid