Healthcare Provider Details

I. General information

NPI: 1710833520
Provider Name (Legal Business Name): WILLOW COUNSELING STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 BURTON ST SE STE 103
GRAND RAPIDS MI
49546-4833
US

IV. Provider business mailing address

1919 CHAMBERLAIN AVE SE
GRAND RAPIDS MI
49506-4638
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-0671
  • Fax:
Mailing address:
  • Phone: 616-229-0671
  • 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: KYLENE RENEE DALTON-KOONS
Title or Position: OWNER/THERAPIST
Credential: LMSW
Phone: 616-706-3951