Basic Information
| Provider Information | |||||||||
| NPI: | 1619533577 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOINONIA COUNSELING CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KOINONIA COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2566 22 MILE RD NW | ||||||||
| Address2: | |||||||||
| City: | KENT CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493309203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162089337 | ||||||||
| FaxNumber: | 6162089337 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 BYRON CENTER AVE SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495193260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162089337 | ||||||||
| FaxNumber: | 6162089337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | RICE | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6162089337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LLPC | ||||||||
| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 14470467 | 01 | CAQH | OTHER |