Provider Demographics
NPI:1508502667
Name:BROEKHUIZEN, ALISON JOY
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:JOY
Last Name:BROEKHUIZEN
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 1:3425 HARVESTWAY CT
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-8702
Mailing Address - Country:US
Mailing Address - Phone:616-836-1402
Mailing Address - Fax:
Practice Address - Street 1:706 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9607
Practice Address - Country:US
Practice Address - Phone:269-639-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant