Healthcare Provider Details

I. General information

NPI: 1881317030
Provider Name (Legal Business Name): KORI KLOOSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S WINTERHAWK DR UNIT 107
ST AUGUSTINE FL
32086-3870
US

IV. Provider business mailing address

325 CALIZA CIR APT 8210
ST AUGUSTINE FL
32084-1071
US

V. Phone/Fax

Practice location:
  • Phone: 734-252-6522
  • Fax: 904-217-3914
Mailing address:
  • Phone: 248-494-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: