Healthcare Provider Details

I. General information

NPI: 1982207924
Provider Name (Legal Business Name): KALEE KORONKA MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KALEE NICHOLSON MA, LPC

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 01/13/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 HARRIS AVE
TAWAS CITY MI
48763-9681
US

IV. Provider business mailing address

P.O. BOX 310 1199 W. HARRIS AVE.
TAWAS CITY MI
48764
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-8636
  • Fax: 989-362-7800
Mailing address:
  • Phone: 989-362-8636
  • Fax: 989-362-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401223667
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: