Provider Demographics
NPI:1558664086
Name:KOOISTRA, LYNDSEY (OTRL)
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-8919
Mailing Address - Country:US
Mailing Address - Phone:616-893-9220
Mailing Address - Fax:
Practice Address - Street 1:308 S MAIN
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8925
Practice Address - Country:US
Practice Address - Phone:616-696-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2010-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007606225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist