Provider Demographics
NPI:1295565570
Name:KINGSLEY, FONDA (LLMSW)
Entity type:Individual
Prefix:MS
First Name:FONDA
Middle Name:
Last Name:KINGSLEY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:BUTTERFLY
Other - Middle Name:
Other - Last Name:KINGSLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:233 FULTON ST E STE 222
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3262
Mailing Address - Country:US
Mailing Address - Phone:616-490-3468
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 222
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3262
Practice Address - Country:US
Practice Address - Phone:616-490-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511103481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical