Healthcare Provider Details

I. General information

NPI: 1154583235
Provider Name (Legal Business Name): PEDIATRIC COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N 10TH ST SUITE 200
KALAMAZOO MI
49009-6112
US

IV. Provider business mailing address

950 N 10TH ST SUITE 200
KALAMAZOO MI
49009-6112
US

V. Phone/Fax

Practice location:
  • Phone: 269-372-6500
  • Fax: 269-372-6503
Mailing address:
  • Phone: 269-372-6500
  • Fax: 269-372-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801081725
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. JODI TEN BROEKE
Title or Position: OWNER
Credential:
Phone: 269-372-6500