Healthcare Provider Details

I. General information

NPI: 1720567290
Provider Name (Legal Business Name): WILLIAM BLAKE KOOI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 FOUNTAIN ST NE
GRAND RAPIDS MI
49503-3422
US

IV. Provider business mailing address

534 FOUNTAIN ST NE
GRAND RAPIDS MI
49503-3422
US

V. Phone/Fax

Practice location:
  • Phone: 616-710-1504
  • Fax:
Mailing address:
  • Phone: 616-710-1504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014874
License Number StateMI

VIII. Authorized Official

Name: WILLIAM BLAKE KOOI
Title or Position: OWNER/COUNSELOR
Credential: LPC, NCC, QIDP
Phone: 616-710-1504