Provider Demographics
NPI:1972799609
Name:DEROSA BELMONT, KATHLEEN ANNE (DC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:DEROSA BELMONT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 BRETON ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-957-9100
Mailing Address - Fax:616-957-9111
Practice Address - Street 1:1801 BRETON ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-957-9100
Practice Address - Fax:616-957-9111
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor