Provider Demographics
NPI:1912511866
Name:KOVALCIK, MIRANDA MARIE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:KOVALCIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4344
Mailing Address - Country:US
Mailing Address - Phone:231-557-3903
Mailing Address - Fax:
Practice Address - Street 1:234 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1357
Practice Address - Country:US
Practice Address - Phone:616-607-4476
Practice Address - Fax:833-231-4270
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty