Provider Demographics
NPI:1720567290
Name:WILLIAM BLAKE KOOI
Entity Type:Organization
Organization Name:WILLIAM BLAKE KOOI
Other - Org Name:BLAKE KOOI COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:KOOI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC, QIDP
Authorized Official - Phone:616-710-1504
Mailing Address - Street 1:534 FOUNTAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3422
Mailing Address - Country:US
Mailing Address - Phone:616-710-1504
Mailing Address - Fax:
Practice Address - Street 1:534 FOUNTAIN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3422
Practice Address - Country:US
Practice Address - Phone:616-710-1504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014874101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty