Healthcare Provider Details

I. General information

NPI: 1679007637
Provider Name (Legal Business Name): JUSTYNE ORTQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 KENMOOR AVE SE STE C
GRAND RAPIDS MI
49546-8624
US

IV. Provider business mailing address

781 KENMOOR AVE SE STE C
GRAND RAPIDS MI
49546-8624
US

V. Phone/Fax

Practice location:
  • Phone: 616-638-7408
  • Fax:
Mailing address:
  • Phone: 616-638-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006765
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018810
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: