Provider Demographics
NPI:1174017503
Name:LEWIS GINEBAUGH, KATHRYN JEAN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:LEWIS GINEBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 79TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7241
Mailing Address - Country:US
Mailing Address - Phone:616-890-3292
Mailing Address - Fax:
Practice Address - Street 1:7920 KIRKLAND CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4974
Practice Address - Country:US
Practice Address - Phone:269-381-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist