Samuel Koolhoven-Moore

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

MH18940 Issued in FL

Practice address

1750 17TH St Ste J2
Sarasota, FL 34234-8690

Phone

(941) 552-2075

NPI assigned

Jul 14, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective May 14, 2024 through May 14, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Foundations Family Support LLC

  • Mental Health Counselor
  • Spokane, WA
  • NPI 1083103238
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1626220800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1626220800000",
    "number": "1720650286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8429 CYPRESS LAKE CIR",
            "city": "SARASOTA",
            "state": "FL",
            "postal_code": "342432915",
            "telephone_number": "707-703-0845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1750 17TH ST STE J2",
            "city": "SARASOTA",
            "state": "FL",
            "postal_code": "342348690",
            "telephone_number": "941-552-2075"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOOLHOVEN-MOORE",
        "first_name": "SAMUEL",
        "name_prefix": "Mr.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-07-14",
        "last_updated": "2021-07-14",
        "certification_date": "2021-07-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "FL",
            "license": "MH18940",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisette Miller Kondrad, D.C.
• Thomas J Konecny, DDS
• Brandon David Konkel, M.D.
• Courtney Renae Konkel, D.O.
• Denise D Konstenius, LCSW
• Stephen Kopetskie, PH.D.
• Nancy Lee Kopitnik, DO
• Melvin Mathew Korattiyil, D.M.D.
• John Zachary Korin, MD
• Lea Ann Korkowski, RN

• Mental Health Counselor in Sarasota, FL
• Providers in Sarasota, FL by specialty
• Mental Health Counselor in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.