=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245973767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K & K HOLISTIC COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2022
-----------------------------------------------------
Last Update Date | 04/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 FOUNTAIN ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-289-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 FOUNTAIN ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-289-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | EMILY KOPPENHOFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-289-3002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------