Provider Demographics
NPI:1992163281
Name:WOOLNER, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WOOLNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-281-6372
Mailing Address - Fax:616-281-6459
Practice Address - Street 1:6500 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-9080
Practice Address - Country:US
Practice Address - Phone:616-281-6311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2023-09-18
Deactivation Date:2018-05-22
Deactivation Code:
Reactivation Date:2018-06-14
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103T00000X
MI6351004436103T00000X
CAF1350625390200000X
MI6301019182103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program