Provider Demographics
NPI:1124500384
Name:DEROOS, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:DEROOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8527 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-9472
Mailing Address - Country:US
Mailing Address - Phone:616-953-9516
Mailing Address - Fax:
Practice Address - Street 1:11172 ADAMS ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9163
Practice Address - Country:US
Practice Address - Phone:616-942-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst