Healthcare Provider Details

I. General information

NPI: 1669072526
Provider Name (Legal Business Name): IT'S YOUR JOURNEY COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 BROADWAY ST
SOUTH HAVEN MI
49090-1421
US

IV. Provider business mailing address

418 BROADWAY ST
SOUTH HAVEN MI
49090-1421
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-8708
  • Fax:
Mailing address:
  • Phone: 269-329-8708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KELLIE HAKKEN
Title or Position: OWNER
Credential: LMSW
Phone: 269-329-8708