Healthcare Provider Details

I. General information

NPI: 1629655451
Provider Name (Legal Business Name): KALAMAZOO CHRISTIAN COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 OAKLAND DR
PORTAGE MI
49024-1113
US

IV. Provider business mailing address

5550 OAKLAND DR
PORTAGE MI
49024-1113
US

V. Phone/Fax

Practice location:
  • Phone: 269-348-4331
  • Fax:
Mailing address:
  • Phone: 269-348-4331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CYNTHIA ELLEN GRIMMER
Title or Position: COUNSELOR
Credential: OTR, MA, LLPC
Phone: 269-348-4331