Provider Demographics
NPI:1386910826
Name:KOON, EUGENE MARTIN (LBSW)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:MARTIN
Last Name:KOON
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 SHARON AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2223
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:616-242-6057
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:616-242-6057
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802084210104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker