Provider Demographics
NPI:1063984862
Name:PALMBOS, KELLIE MARIE (MSW)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:PALMBOS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW, MSW
Mailing Address - Street 1:4589 EQUESTRIAN DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7493
Mailing Address - Country:US
Mailing Address - Phone:616-450-5446
Mailing Address - Fax:
Practice Address - Street 1:2100 RAYBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7759
Practice Address - Country:US
Practice Address - Phone:616-540-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085935104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker