Provider Demographics
NPI:1235993551
Name:BOORSMA, MELISSA BETH
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:BETH
Last Name:BOORSMA
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 1:346 68TH ST SW
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7179
Mailing Address - Country:US
Mailing Address - Phone:616-202-5161
Mailing Address - Fax:
Practice Address - Street 1:21777 KENOWA AVE
Practice Address - Street 2:
Practice Address - City:CONKLIN
Practice Address - State:MI
Practice Address - Zip Code:49403-8726
Practice Address - Country:US
Practice Address - Phone:616-780-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician