Provider Demographics
NPI:1891928198
Name:KACHOREK, JUSTIN ROBERT (LLC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:KACHOREK
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:
Practice Address - Street 1:6549 TOWN CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4824
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022402101YP2500X
WAMC60230791101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional