Provider Demographics
NPI:1659828093
Name:KOSTER, MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KOSTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 5061
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CHOME MISUMIMACHI
Practice Address - Street 2:
Practice Address - City:IWAUNKI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:315-255-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0810006447103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty