MEDICARE: KBK COUNSELING SERVICES, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801066233	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0899799	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295024487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KBK COUNSELING SERVICES, P.C.

Provider Business Mailing Address
First Line	:	5316 BREEZE HILL PL
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48098-2725
Country	:	US
Telephone Number	:	248-952-5853
Fax Number	:

Provider Business Practice Location Address
First Line	:	39520 WOODWARD AVE
Second Line	:	SUITE 233
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-5054
Country	:	US
Telephone Number	:	586-216-4553
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. KIM BETH KETOLA
Credential	:	LMSW
Telephone Number	:	586-216-4553

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	03/29/2011

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