Healthcare Provider Details

I. General information

NPI: 1912396516
Provider Name (Legal Business Name): PETER JOHN KOSHAR JR. LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57418 COUNTY ROAD 681
HARTFORD MI
49057-9421
US

IV. Provider business mailing address

57418 COUNTY ROAD 681 STE B
HARTFORD MI
49057-9422
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-5574
  • Fax:
Mailing address:
  • Phone: 269-657-5574
  • Fax: 269-445-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: