MEDICARE: KOINONIA CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP1600X	Pastoral Counselor
2	103TB0200X	Cognitive & Behavioral Psychologist
3	103TC0700X	Clinical Psychologist
4	103TC1900X	Counseling Psychologist
5	103TH0100X	Health Service Psychologist
6	106H00000X	Marriage & Family Therapist
7	101Y00000X	Counselor

General Provider Information

NPI Number	:	1760036842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOINONIA CENTER LLC

Provider Business Mailing Address
First Line	:	11507 S KEENEY RD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99224-9625
Country	:	US
Telephone Number	:	509-850-2377
Fax Number	:

Provider Business Practice Location Address
First Line	:	11507 S KEENEY RD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99224-9625
Country	:	US
Telephone Number	:	509-850-2377
Fax Number	:

Authorized Official
Title or Position	:	GOVERNOR
Name	:	CHRISTI ORTIZ
Credential	:	LMFT
Telephone Number	:	509-993-2968

Provider Enumeration Date	:	07/28/2019
Last Update Date	:	08/07/2023

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Directions to “KOINONIA CENTER LLC ” Practice Location

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