Healthcare Provider Details

I. General information

NPI: 1396226312
Provider Name (Legal Business Name): LOUKAS NICHOLAS KONDYLES LIMITED LICENSE COUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 KENMOOR AVE SE STE C
GRAND RAPIDS MI
49546-8624
US

IV. Provider business mailing address

331 EUREKA AVE SE UPPR
GRAND RAPIDS MI
49506-1503
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-4462
  • Fax:
Mailing address:
  • Phone: 616-259-4462
  • Fax: 616-828-1936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: