Provider Demographics
NPI:1134146178
Name:BOONSTRA, PETRA
Entity Type:Individual
Prefix:MRS
First Name:PETRA
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:
Other - Last Name:SCHWELLNUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DRIVE
Mailing Address - Street 2:SUITE 2016
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-434-3200
Mailing Address - Fax:734-712-3358
Practice Address - Street 1:5333 MCAULEY DRIVE
Practice Address - Street 2:SUITE 2016
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-434-3200
Practice Address - Fax:734-712-3358
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000029231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN71660008Medicare PIN
MIN71920018Medicare PIN
MI1134146178Medicaid