Provider Demographics
NPI:1841434305
Name:OPPEWAL, ELIZABETH BOUWSMA (MA LLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BOUWSMA
Last Name:OPPEWAL
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:OPPEWAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LLP
Mailing Address - Street 1:644 HAWTHORNE ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3412
Mailing Address - Country:US
Mailing Address - Phone:616-443-8379
Mailing Address - Fax:269-686-4601
Practice Address - Street 1:277 NORTH ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1138
Practice Address - Country:US
Practice Address - Phone:269-673-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009033103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist