Basic Information
| Provider Information | |||||||||
| NPI: | 1144611666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORNOELY | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2118 3 MILE ROAD NW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162223720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2118 3 MILE ROAD NW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162223720 | ||||||||
| FaxNumber: | 6162223724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2015 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801097222 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.