Provider Demographics
NPI:1124995097
Name:PLASTER, KELLI JOY
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JOY
Last Name:PLASTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1009
Mailing Address - Country:US
Mailing Address - Phone:616-312-4689
Mailing Address - Fax:
Practice Address - Street 1:4370 CHICAGO DR SW STE 735
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1694
Practice Address - Country:US
Practice Address - Phone:616-341-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician