Healthcare Provider Details

I. General information

NPI: 1285857227
Provider Name (Legal Business Name): BRENDA JOY HAAKSMA M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19501 MISTY RIDGE LN
TRABUCO CANYON CA
92679-1602
US

IV. Provider business mailing address

19501 MISTY RIDGE LN
TRABUCO CANYON CA
92679-1602
US

V. Phone/Fax

Practice location:
  • Phone: 616-745-8308
  • Fax:
Mailing address:
  • Phone: 616-745-8308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01109430
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number33135
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.0000730
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: