Provider Demographics
NPI:1790226413
Name:KOOISTRA & ASSOCIATES PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:KOOISTRA & ASSOCIATES PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOOISTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-638-7557
Mailing Address - Street 1:41 WASHINGTON AVE
Mailing Address - Street 2:SUITE 365
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1390
Mailing Address - Country:US
Mailing Address - Phone:616-638-7557
Mailing Address - Fax:
Practice Address - Street 1:41 WASHINGTON AVE
Practice Address - Street 2:SUITE 365
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1390
Practice Address - Country:US
Practice Address - Phone:616-638-7557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007943103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty