Provider Demographics
NPI:1679007637
Name:ORTQUIST, JUSTYNE
Entity Type:Individual
Prefix:
First Name:JUSTYNE
Middle Name:
Last Name:ORTQUIST
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 1:781 KENMOOR AVE SE STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8624
Mailing Address - Country:US
Mailing Address - Phone:616-638-7408
Mailing Address - Fax:
Practice Address - Street 1:781 KENMOOR AVE SE STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8624
Practice Address - Country:US
Practice Address - Phone:616-638-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006765106H00000X
MI6401018810101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist