Provider Demographics
NPI:1225154800
Name:KELLY, BRENDAN NEUBECKER (LMSW)
Entity Type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:NEUBECKER
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 FRONT AVE NW STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7513
Mailing Address - Country:US
Mailing Address - Phone:616-458-6870
Mailing Address - Fax:616-458-6874
Practice Address - Street 1:1118 FRONT AVE NW STE 1
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504
Practice Address - Country:US
Practice Address - Phone:616-458-6870
Practice Address - Fax:616-458-6874
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010873011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI443587Medicaid