Healthcare Provider Details

I. General information

NPI: 1780079210
Provider Name (Legal Business Name): KOINONIA PROFESSIONAL COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 209E
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

233 FULTON ST E STE 209E
GRAND RAPIDS MI
49503-3200
US

V. Phone/Fax

Practice location:
  • Phone: 616-279-9978
  • Fax: 616-724-4331
Mailing address:
  • Phone: 616-279-9978
  • Fax: 616-724-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009315
License Number StateMI

VIII. Authorized Official

Name: MR. ISAAC GORDON WATTS
Title or Position: OWNER
Credential: MA, LPC
Phone: 616-818-6637