Provider Demographics
NPI:1972938132
Name:BRANCH, KELLY LYNN (MA, LPC, LLMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BRANCH
Suffix:
Gender:F
Credentials:MA, LPC, LLMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:AMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8488 TUCKER CT
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8678
Mailing Address - Country:US
Mailing Address - Phone:616-299-4305
Mailing Address - Fax:
Practice Address - Street 1:901 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1201
Practice Address - Country:US
Practice Address - Phone:616-299-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012214101YP2500X
MI4101006468106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist