Basic Information
| Provider Information | |||||||||
| NPI: | 1811249691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOON | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | E.W. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC, LCAC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 ROLLINGROCK DR | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493411197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174480228 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 805 LEONARD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164512021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2012 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A9927 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | A9927 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC1900X | 6401016578 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling | 101YA0400X | 87001563A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 3072-A | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 000000000 | 05 | MI | MEDICAID |