Provider Demographics
NPI:1629898101
Name:SEGERSTROM, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SEGERSTROM
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 1:4203 K RD
Mailing Address - Street 2:
Mailing Address - City:BARK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49807-9739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 7TH AVE S
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1176
Practice Address - Country:US
Practice Address - Phone:906-233-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851119182104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker