Healthcare Provider Details

I. General information

NPI: 1457899205
Provider Name (Legal Business Name): THOMAS KORYOM LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 IONIA AVE NW
GRAND RAPIDS MI
49503-1020
US

IV. Provider business mailing address

1131 IONIA AVE NW
GRAND RAPIDS MI
49503-1020
US

V. Phone/Fax

Practice location:
  • Phone: 616-269-7900
  • Fax: 616-259-7909
Mailing address:
  • Phone: 616-269-7900
  • Fax: 616-259-7909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401015880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: