1144763103 NPI number — PATRICIA BOONSTRA MSW

Table of content: PATRICIA BOONSTRA MSW (NPI 1144763103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144763103 NPI number — PATRICIA BOONSTRA MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONSTRA
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOES
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144763103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 EASTERN AVENUE
Provider Second Line Business Mailing Address:
BETHANY CHRISTIAN SERVICES
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-396-0623
Provider Business Mailing Address Fax Number:
616-396-2315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 EASTERN AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-224-7550
Provider Business Practice Location Address Fax Number:
616-224-7593
Provider Enumeration Date:
11/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801018434 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ON66280 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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