Provider Demographics
NPI:1235363763
Name:KOOISTRA, JOANNE E
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:E
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7154
Mailing Address - Country:US
Mailing Address - Phone:360-414-2000
Mailing Address - Fax:
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2236
Practice Address - Fax:360-414-2788
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600842921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical