Provider Demographics
NPI:1447567599
Name:KLOOSTERMAN, MARCIE B (SLP)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:B
Last Name:KLOOSTERMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARCIE
Other - Middle Name:B
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:23375 AMBER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-8139
Mailing Address - Country:US
Mailing Address - Phone:219-688-2348
Mailing Address - Fax:
Practice Address - Street 1:23375 AMBER VALLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-8139
Practice Address - Country:US
Practice Address - Phone:219-688-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004143A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist