Provider Demographics
NPI:1467854034
Name:PURDUE, KELLY ELIZABETH (MSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:PURDUE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4626
Mailing Address - Country:US
Mailing Address - Phone:616-458-1187
Mailing Address - Fax:616-458-7113
Practice Address - Street 1:456 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4626
Practice Address - Country:US
Practice Address - Phone:616-458-1187
Practice Address - Fax:616-458-7113
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010629931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical