Provider Demographics
NPI:1851665236
Name:KOOISTRA, ELIZABETH TIFFANY (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TIFFANY
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20350 KENSINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5949
Mailing Address - Country:US
Mailing Address - Phone:612-270-7015
Mailing Address - Fax:
Practice Address - Street 1:20350 KENSINGTON WAY
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5949
Practice Address - Country:US
Practice Address - Phone:612-270-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst