Provider Demographics
NPI:1699234021
Name:KEITH, KEVIN HASTINGS (LLMSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:HASTINGS
Last Name:KEITH
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 BROOKLANE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3557
Mailing Address - Country:US
Mailing Address - Phone:269-312-9591
Mailing Address - Fax:
Practice Address - Street 1:385 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1129
Practice Address - Country:US
Practice Address - Phone:616-454-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102428104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker