Provider Demographics
NPI:1417371337
Name:TWORK, KHALIA RENITA (LLPC)
Entity Type:Individual
Prefix:
First Name:KHALIA
Middle Name:RENITA
Last Name:TWORK
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:KHALIA
Other - Middle Name:RENITA
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:SUITE 258
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5938
Mailing Address - Country:US
Mailing Address - Phone:616-295-7614
Mailing Address - Fax:
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:SUITE 258
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5938
Practice Address - Country:US
Practice Address - Phone:616-295-7614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013477101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health