Healthcare Provider Details

I. General information

NPI: 1023473121
Provider Name (Legal Business Name): LUCAS KOOLE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5000
  • Fax: 616-455-5960
Mailing address:
  • Phone: 616-455-5000
  • Fax: 616-455-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60629508
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: