Healthcare Provider Details

I. General information

NPI: 1164595526
Provider Name (Legal Business Name): KRISTINE A KOETJE MA LPC LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINE A WILDER MA LPC LLP

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17224 VAN WAGONER RD
SPRING LAKE MI
49456-9702
US

IV. Provider business mailing address

17224 VAN WAGONER RD STE B
SPRING LAKE MI
49456-9702
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-2130
  • Fax: 162-962-1486
Mailing address:
  • Phone: 616-296-2130
  • Fax: 616-296-2148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401002021
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: