Basic Information
| Provider Information | |||||||||
| NPI: | 1225421035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW, CAADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER | ||||||||
| OtherFirstName: | KELLY | ||||||||
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| OtherCredential: | LMSW, CAADC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 466 SUNBROOK ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495087708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 EASTERN AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165169345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2015 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C-03928 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 6801097916 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.