Healthcare Provider Details

I. General information

NPI: 1609131192
Provider Name (Legal Business Name): KRISTINE KOETJE MA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
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
SPRING LAKE MI
49456-9702
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-2130
  • Fax: 616-296-2148
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTINE E KOETJE-BALDER
Title or Position: DIRECTOR
Credential: MA LLP
Phone: 231-799-8182