Provider Demographics
NPI:1821485475
Name:KELM, CRYSTAL (LBSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KELM
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-8627
Mailing Address - Country:US
Mailing Address - Phone:269-208-0986
Mailing Address - Fax:
Practice Address - Street 1:277 NORTH ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1138
Practice Address - Country:US
Practice Address - Phone:269-673-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085236104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802085236Medicaid