=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710562822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIVOT COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2021
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 S STATE ST STE 320
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-422-7820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 S STATE ST STE 320
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-422-7820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | KRIS PENCE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 616-422-7820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------