Provider Demographics
NPI:1609015890
Name:VEENSTRA, MYRON JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:JOSEPH
Last Name:VEENSTRA
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 1:20531 US HIGHWAY 75 SW
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-9045
Mailing Address - Country:US
Mailing Address - Phone:218-281-3351
Mailing Address - Fax:218-281-1947
Practice Address - Street 1:20531 US HIGHWAY 75 SW
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-9045
Practice Address - Country:US
Practice Address - Phone:218-281-3351
Practice Address - Fax:218-281-1947
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
ND103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist