Healthcare Provider Details

I. General information

NPI: 1174051619
Provider Name (Legal Business Name): KANAAN THERAPY AND BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2017
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 EAST MICHIGAN AVENUE SUITE 103
PAW PAW MI
49079-9510
US

IV. Provider business mailing address

816 EAST MICHIGAN AVENUE SUITE 103
PAW PAW MI
49079-9510
US

V. Phone/Fax

Practice location:
  • Phone: 269-815-8168
  • Fax:
Mailing address:
  • Phone: 269-815-8168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401012892
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092614
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY ADLI KANAAN
Title or Position: OWNER/PARTNER
Credential: LPC
Phone: 269-815-8168