Provider Demographics
NPI:1225838097
Name:RIETKERK, KATIE ROMAINE (LLPC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ROMAINE
Last Name:RIETKERK
Suffix:
Gender:
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 COLLEGE AVE NE APT 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2920 FULLER AVE NE STE 203
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3458
Practice Address - Country:US
Practice Address - Phone:269-615-8942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health