Provider Demographics
NPI:1124416052
Name:VANAKEN, KELLY LYNN (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:VANAKEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE A100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8404
Practice Address - Country:US
Practice Address - Phone:517-618-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011055501041C0700X, 104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical