Provider Demographics
NPI:1023110863
Name:KOEDAM, WILHELMINA SINY (PHD)
Entity type:Individual
Prefix:DR
First Name:WILHELMINA
Middle Name:SINY
Last Name:KOEDAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-1607
Mailing Address - Country:US
Mailing Address - Phone:954-895-4248
Mailing Address - Fax:954-921-5200
Practice Address - Street 1:134 S DIXIE HWY STE 104
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-5423
Practice Address - Country:US
Practice Address - Phone:954-895-4248
Practice Address - Fax:954-921-5200
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650030104OtherTAX ID