Healthcare Provider Details

I. General information

NPI: 1063941599
Provider Name (Legal Business Name): INNER PEACE COUNSELING, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 S 9TH ST
KALAMAZOO MI
49009-8120
US

IV. Provider business mailing address

4155 S 9TH ST
KALAMAZOO MI
49009-8120
US

V. Phone/Fax

Practice location:
  • Phone: 269-213-5002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801098813
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006666
License Number StateMI

VIII. Authorized Official

Name: ASHLEY YOUNGBLOOD
Title or Position: PSYCHOTHERAPIST
Credential:
Phone: 269-213-5002