Provider Demographics
NPI:1104481902
Name:KOINONIA BAPTIST CHURCH
Entity type:Organization
Organization Name:KOINONIA BAPTIST CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:972-977-5974
Mailing Address - Street 1:2455 SE GREEN OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-1970
Mailing Address - Country:US
Mailing Address - Phone:817-466-8211
Mailing Address - Fax:
Practice Address - Street 1:2455 SE GREEN OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1970
Practice Address - Country:US
Practice Address - Phone:817-466-8211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty