Provider Demographics
NPI:1164595526
Name:KOETJE, KRISTINE A (MA LLP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:KOETJE
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:A
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5353 GRAND HAVEN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5985
Mailing Address - Country:US
Mailing Address - Phone:231-799-8182
Mailing Address - Fax:231-799-8183
Practice Address - Street 1:5353 GRAND HAVEN RD
Practice Address - Street 2:SUITE B
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-5985
Practice Address - Country:US
Practice Address - Phone:231-799-8182
Practice Address - Fax:231-799-8183
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008186103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist