Healthcare Provider Details

I. General information

NPI: 1144611666
Provider Name (Legal Business Name): STEPHEN KORNOELY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 3 MILE ROAD NW
GRAND RAPIDS MI
49544
US

IV. Provider business mailing address

2118 3 MILE ROAD NW
GRAND RAPIDS MI
49544
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-3720
  • Fax: 616-222-3724
Mailing address:
  • Phone: 616-222-3720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097222
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: