MEDICARE: KOINONIA COUNSELING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	LPC0812	TN

General Provider Information

NPI Number	:	1225220700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOINONIA COUNSELING CENTER

Provider Business Mailing Address
First Line	:	3343 DEWINE RD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-4211
Country	:	US
Telephone Number	:	865-584-6374
Fax Number	:	865-584-6613

Provider Business Practice Location Address
First Line	:	3343 DEWINE RD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-4211
Country	:	US
Telephone Number	:	865-584-6374
Fax Number	:	865-584-6613

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	DR. CHARLES SANDERFUR
Credential	:	LPC, M.ED
Telephone Number	:	865-584-6374

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	08/17/2007

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