Provider Demographics
NPI:1366819815
Name:VANASSCHE, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:VANASSCHE
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 1:15930 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1155
Mailing Address - Country:US
Mailing Address - Phone:586-464-0175
Mailing Address - Fax:
Practice Address - Street 1:560 SYLVAN AVE STE 1110
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-3118
Practice Address - Country:US
Practice Address - Phone:646-873-6600
Practice Address - Fax:646-859-4440
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI1-22-58779103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other