Basic Information
| Provider Information | |||||||||
| NPI: | 1235363763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOOISTRA | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986327154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142236 | ||||||||
| FaxNumber: | 3604142788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW60084292 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.