Healthcare Provider Details

I. General information

NPI: 1609432996
Provider Name (Legal Business Name): ROBB KORNOELJE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 TROWBRIDGE ST NE APT 208
GRAND RAPIDS MI
49503-1891
US

IV. Provider business mailing address

221 TROWBRIDGE ST NE APT 208
GRAND RAPIDS MI
49503-1891
US

V. Phone/Fax

Practice location:
  • Phone: 616-499-7711
  • Fax:
Mailing address:
  • Phone: 616-499-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: