=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679227201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTA KOPCHICK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2022
-----------------------------------------------------
Last Update Date | 11/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 LEONARD ST NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49505-5515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-402-7760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 HASKINS CT SE
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49301-7899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-402-7760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | KRISTA LYNN KOPCHICK
-----------------------------------------------------
Credential | LMSW, CST
-----------------------------------------------------
Telephone | 616-402-7760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------