Provider Demographics
NPI:1285857227
Name:HAAKSMA, BRENDA JOY (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JOY
Last Name:HAAKSMA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2032 S CROSS CREEK DR SE STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8780
Mailing Address - Country:US
Mailing Address - Phone:616-745-8308
Mailing Address - Fax:
Practice Address - Street 1:2032 S CROSS CREEK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-8780
Practice Address - Country:US
Practice Address - Phone:616-745-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000730235Z00000X
MI01109430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99556502Medicaid