Basic Information
| Provider Information | |||||||||
| NPI: | 1811263288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEPUE | ||||||||
| FirstName: | KAYLEEN | ||||||||
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| Credential: | LPC, CCS, CADC, LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3351 CLAYSTONE ST SE STE 212 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658282 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658282 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146M00000X | 3202002671 | MI | N | Emergency Medical Service Providers | Emergency Medical Technician, Intermediate | 1041C0700X | 6802085626 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 6401014423 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.