Provider Demographics
NPI:1750893210
Name:KILLINGHAM, KERBY KEYLON
Entity type:Individual
Prefix:
First Name:KERBY
Middle Name:KEYLON
Last Name:KILLINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 S DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:1501 WIDDICOMB AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3048
Practice Address - Country:US
Practice Address - Phone:616-856-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health