Provider Demographics
NPI:1144763103
Name:BOONSTRA, PATRICIA (MSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LYNN
Other - Last Name:BOES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 EASTERN AVENUE
Mailing Address - Street 2:BETHANY CHRISTIAN SERVICES
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501
Mailing Address - Country:US
Mailing Address - Phone:616-396-0623
Mailing Address - Fax:616-396-2315
Practice Address - Street 1:901 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1201
Practice Address - Country:US
Practice Address - Phone:616-224-7550
Practice Address - Fax:616-224-7593
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010184341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION66280Medicaid