Provider Demographics
NPI:1194116103
Name:BOESKOOL, ELISHA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:BOESKOOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 68TH ST SW STE 150
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7145
Mailing Address - Country:US
Mailing Address - Phone:616-970-5349
Mailing Address - Fax:
Practice Address - Street 1:160 68TH ST SW STE 150
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7145
Practice Address - Country:US
Practice Address - Phone:616-612-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088047171M00000X
MI6802091236104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator