Basic Information
| Provider Information | |||||||||
| NPI: | 1538517016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN GEMERT | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481985752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443000 | ||||||||
| FaxNumber: | 7345446732 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443050 | ||||||||
| FaxNumber: | 7345446732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801099415 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 6801106566 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.