Provider Demographics
NPI:1508040627
Name:KOOISTRA, WILLIAM P (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
Last Name:KOOISTRA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WASHINGTON AVE
Mailing Address - Street 2:STE 365
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-3304
Mailing Address - Country:US
Mailing Address - Phone:616-638-7557
Mailing Address - Fax:
Practice Address - Street 1:41 WASHINGTON AVE
Practice Address - Street 2:STE 365
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-3304
Practice Address - Country:US
Practice Address - Phone:616-399-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007943103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical