Provider Demographics
NPI:1972543718
Name:VLIETSTRA, CHRISTINE NOEL (MS, OT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:NOEL
Last Name:VLIETSTRA
Suffix:
Gender:F
Credentials:MS, OT
Other - Prefix:MISS
Other - First Name:CHRISTINE
Other - Middle Name:NOEL
Other - Last Name:POOSAWTSEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OT
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8419
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M-230
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-349-8601
Practice Address - Fax:269-349-6446
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005582225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P07860002Medicare ID - Type Unspecified
Q33144Medicare UPIN