Provider Demographics
NPI:1164595526
Name:KOETJE, KRISTINE A (MA LPC LLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:KOETJE
Suffix:
Gender:F
Credentials:MA LPC LLP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:A
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LPC LLP
Mailing Address - Street 1:17224 VAN WAGONER RD STE B
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-296-2130
Mailing Address - Fax:616-296-2148
Practice Address - Street 1:17224 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-296-2130
Practice Address - Fax:162-962-1486
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002021101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor