Healthcare Provider Details

I. General information

NPI: 1629842067
Provider Name (Legal Business Name): KOA HEALTH DIGITAL SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 STATE ST FL 16
BOSTON MA
02109-1466
US

IV. Provider business mailing address

75 STATE ST FL 16
BOSTON MA
02109-1466
US

V. Phone/Fax

Practice location:
  • Phone: 617-619-8234
  • Fax:
Mailing address:
  • Phone: 617-619-8234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: RENEE M ANDERSON-DRAP
Title or Position: VICE PRESIDENT, DELIVERY & SERVICES
Credential:
Phone: 248-818-7802