Healthcare Provider Details

I. General information

NPI: 1689367591
Provider Name (Legal Business Name): CHRISTOPHER JOHN KOWAL MA, LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OAKLAND AVE SW
GRAND RAPIDS MI
49503-5057
US

IV. Provider business mailing address

6895 MYERS LAKE AVE NE
ROCKFORD MI
49341-8881
US

V. Phone/Fax

Practice location:
  • Phone: 616-819-2947
  • Fax:
Mailing address:
  • Phone: 248-798-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: