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General NPI Number Information
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NPI Number | 1215581384
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Entity Type | Organization
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Legal Business Name | PORTAGE COUNSELING AND COACHING
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Dates
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Enumeration Date | 07/27/2019
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Last Update Date | 07/27/2019
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Provider Practice Location Address
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Address Line | 10032 SHAVER RD
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City | PORTAGE
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State | MI
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Zip | 49024-6738
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Country | US
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Telephone | 269-998-8183
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Fax |
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Provider Business Mailing Address
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Address Line | 5380 HOLIDAY TER STE 32
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City | KALAMAZOO
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State | MI
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Zip | 49009-2128
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GERALD BROOKS
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Credential |
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Telephone | 269-998-8183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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