Provider Demographics
NPI:1396202305
Name:GEISELMAN, KEITH EDWARD (MDIV, LLMSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:EDWARD
Last Name:GEISELMAN
Suffix:
Gender:M
Credentials:MDIV, LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4398 CHAD CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9478
Mailing Address - Country:US
Mailing Address - Phone:734-604-7910
Mailing Address - Fax:
Practice Address - Street 1:2901 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8548
Practice Address - Country:US
Practice Address - Phone:517-548-1537
Practice Address - Fax:517-548-9399
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011037041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical