Healthcare Provider Details

I. General information

NPI: 1679227201
Provider Name (Legal Business Name): KRISTA KOPCHICK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

377 HASKINS CT SE
ADA MI
49301-7899
US

V. Phone/Fax

Practice location:
  • Phone: 616-402-7760
  • Fax:
Mailing address:
  • Phone: 616-402-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KRISTA LYNN KOPCHICK
Title or Position: PSYCHOTHERAPIST
Credential: LMSW, CST
Phone: 616-402-7760