Provider Demographics
NPI:1174786735
Name:GRIFFIN, KELLY A (MA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 CELEBRATION DR NE STE 212
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9200
Mailing Address - Country:US
Mailing Address - Phone:616-262-2494
Mailing Address - Fax:
Practice Address - Street 1:2090 CELEBRATION DR NE STE 212
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9200
Practice Address - Country:US
Practice Address - Phone:616-262-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010544103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist