Provider Demographics
NPI:1366889313
Name:BARAKA, PATIENT KATABANA (LLMSW)
Entity type:Individual
Prefix:
First Name:PATIENT
Middle Name:KATABANA
Last Name:BARAKA
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 ANTOINE ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1001
Mailing Address - Country:US
Mailing Address - Phone:616-988-1479
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:255 COLRAIN ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-1013
Practice Address - Country:US
Practice Address - Phone:616-988-1479
Practice Address - Fax:616-245-0450
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health