Provider Demographics
NPI:1821566563
Name:KOOPS, ANNISE (LLMSW)
Entity Type:Individual
Prefix:
First Name:ANNISE
Middle Name:
Last Name:KOOPS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 S RIVER AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2848
Mailing Address - Country:US
Mailing Address - Phone:616-377-4899
Mailing Address - Fax:
Practice Address - Street 1:186 S RIVER AVE STE 5
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2848
Practice Address - Country:US
Practice Address - Phone:616-377-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102078104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801102078OtherSTATE OF MICHIGAN- DEPARTMENT OF LICENSING/REGULATORY AFFAIRS