Provider Demographics
NPI:1497986616
Name:PELTZ, KIMBERLY ROSE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:PELTZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 CRIBBINS RD
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:MI
Mailing Address - Zip Code:48049-2809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 KRAFFT RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3565
Practice Address - Country:US
Practice Address - Phone:810-985-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680110913991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical