MEDICARE: HEART'S JOURNEY WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301013131	MI

General Provider Information

NPI Number	:	1619214699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART'S JOURNEY WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	6189 LAKE MICHIGAN DR
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-9244
Country	:	US
Telephone Number	:	616-307-1617
Fax Number	:	616-588-6046

Provider Business Practice Location Address
First Line	:	6189 LAKE MICHIGAN DR
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-9244
Country	:	US
Telephone Number	:	616-307-1617
Fax Number	:	616-588-6046

Authorized Official
Title or Position	:	OWNER/CLINICIAN
Name	:	DR. SUSAN MARIE DILSWORTH
Credential	:	PHD
Telephone Number	:	616-307-1617

Provider Enumeration Date	:	01/10/2013
Last Update Date	:	01/10/2013

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