Provider Demographics
NPI:1669208864
Name:KELSO, PAIGE ELEANOR (LLMSW)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:ELEANOR
Last Name:KELSO
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MRS
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:SWEET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLMSU
Mailing Address - Street 1:208 DEWITT LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1923
Mailing Address - Country:US
Mailing Address - Phone:616-570-2257
Mailing Address - Fax:
Practice Address - Street 1:600 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2178
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:616-805-3631
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511189071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical